Provider Demographics
NPI:1740899590
Name:AMUNDSEN, CAILIN ALIVIA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:CAILIN
Middle Name:ALIVIA
Last Name:AMUNDSEN
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 1:777 GOGUAC ST W STE B2
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:49015-2097
Mailing Address - Country:US
Mailing Address - Phone:269-223-7786
Mailing Address - Fax:
Practice Address - Street 1:777 GOGUAC ST W STE B2
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MI
Practice Address - Zip Code:49015-2097
Practice Address - Country:US
Practice Address - Phone:269-223-7786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00000000000Medicaid