Provider Demographics
NPI:1134440563
Name:GUNSAULLUS, AMY (SLP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:GUNSAULLUS
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 1:282 PRAIRIE SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-9565
Mailing Address - Country:US
Mailing Address - Phone:847-740-1340
Mailing Address - Fax:
Practice Address - Street 1:282 PRAIRIE SPRINGS DR
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-9565
Practice Address - Country:US
Practice Address - Phone:847-740-1340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.004400235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist