Provider Demographics
NPI:1932231958
Name:RUNDSTROM, TERESSA SUSANNE (MS ED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TERESSA
Middle Name:SUSANNE
Last Name:RUNDSTROM
Suffix:
Gender:F
Credentials:MS ED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7030 KILGORE RD
Mailing Address - Street 2:
Mailing Address - City:GIBBON
Mailing Address - State:NE
Mailing Address - Zip Code:68840-3089
Mailing Address - Country:US
Mailing Address - Phone:308-440-8648
Mailing Address - Fax:
Practice Address - Street 1:3112 ANTELOPE AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-9781
Practice Address - Country:US
Practice Address - Phone:308-338-9238
Practice Address - Fax:308-338-9208
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE903235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist