Provider Demographics
NPI:1245505957
Name:GUNDLACH, AMY MARIE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:GUNDLACH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:WEGSCHEID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:309 WASHINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278
Mailing Address - Country:US
Mailing Address - Phone:320-839-4271
Mailing Address - Fax:320-839-4196
Practice Address - Street 1:15620 EDGEWOOD DRIVE
Practice Address - Street 2:SUITE 240
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425
Practice Address - Country:US
Practice Address - Phone:218-454-7012
Practice Address - Fax:218-454-7015
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8722235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist