Basic Information
| Provider Information | |||||||||
| NPI: | 1447506456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUNTUPALLI | ||||||||
| FirstName: | CHAYADEVIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D., CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NANJUNDESWARAN | ||||||||
| OtherFirstName: | CHAYADEVIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D., CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394584 | ||||||||
| FaxNumber: | 4234394607 | ||||||||
| Practice Location | |||||||||
| Address1: | 156 S DOSSETT DRIVE | ||||||||
| Address2: | BOX 70643 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376141702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394355 | ||||||||
| FaxNumber: | 4234394607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2012 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP0000004423 | TN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 1529475 | 05 | TN | MEDICAID | 12114054 | 01 | TN | ASHA | OTHER | SP0000004423 | 01 | TN | ST LICENSE | OTHER |