Provider Demographics
NPI:1851531578
Name:GUNDERSON, CHER NICOLLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CHER
Middle Name:NICOLLE
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 STUART ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4313
Mailing Address - Country:US
Mailing Address - Phone:920-362-2359
Mailing Address - Fax:
Practice Address - Street 1:1220 STUART ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4313
Practice Address - Country:US
Practice Address - Phone:920-362-2359
Practice Address - Fax:920-431-0555
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-21
Last Update Date:2009-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2358-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42798900Medicaid