Provider Demographics
NPI:1508928219
Name:GONDAK, REBECCA (SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GONDAK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15945
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4054
Mailing Address - Country:US
Mailing Address - Phone:410-729-4508
Mailing Address - Fax:410-729-4526
Practice Address - Street 1:8638 VETERANS HWY
Practice Address - Street 2:1ST FLOOR
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1422
Practice Address - Country:US
Practice Address - Phone:410-729-4508
Practice Address - Fax:410-729-4526
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD5032235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD220025200Medicaid