Provider Demographics
NPI:1568079119
Name:GONDAK, KARISSA ANN
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:ANN
Last Name:GONDAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 BAKERS RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-1459
Mailing Address - Country:US
Mailing Address - Phone:304-285-0692
Mailing Address - Fax:
Practice Address - Street 1:161 BAKERS RIDGE RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-1459
Practice Address - Country:US
Practice Address - Phone:304-285-0692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV235Z00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist