Basic Information
| Provider Information | |||||||||
| NPI: | 1508928219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONDAK | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15945 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107294508 | ||||||||
| FaxNumber: | 4107294526 | ||||||||
| Practice Location | |||||||||
| Address1: | 8638 VETERANS HWY | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | MILLERSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211081422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107294508 | ||||||||
| FaxNumber: | 4107294526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2006 | ||||||||
| LastUpdateDate: | 12/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 5032 | MD | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 220025200 | 05 | MD | MEDICAID |