Provider Demographics
NPI:1255535019
Name:GAEWJUNDEE, SUDSVAT (PT)
Entity type:Individual
Prefix:MS
First Name:SUDSVAT
Middle Name:
Last Name:GAEWJUNDEE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 MUSEUM BLVD UNIT 405
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-3169
Mailing Address - Country:US
Mailing Address - Phone:479-227-0179
Mailing Address - Fax:
Practice Address - Street 1:100 9TH ST
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-3026
Practice Address - Country:US
Practice Address - Phone:479-394-2617
Practice Address - Fax:479-243-0107
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2532225100000X
IL070007343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist