Provider Demographics
NPI:1518933969
Name:KANDULA, GWEN M (AUD, MBA)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:M
Last Name:KANDULA
Suffix:
Gender:F
Credentials:AUD, MBA
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:M
Other - Last Name:VAN ROOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD, MBA
Mailing Address - Street 1:14150 CHESTERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2381
Mailing Address - Country:US
Mailing Address - Phone:414-771-6780
Mailing Address - Fax:414-238-2424
Practice Address - Street 1:1233 N MAYFAIR RD
Practice Address - Street 2:STE 120
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3255
Practice Address - Country:US
Practice Address - Phone:414-771-6780
Practice Address - Fax:414-238-2424
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI434 156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41146700Medicaid