Provider Demographics
NPI:1760010896
Name:GOSTOMELSKY, AMY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GOSTOMELSKY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1152 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4166
Mailing Address - Country:US
Mailing Address - Phone:847-997-4907
Mailing Address - Fax:
Practice Address - Street 1:10 W PHILLIP RD STE 108
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1730
Practice Address - Country:US
Practice Address - Phone:847-997-4907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146015253235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist