Basic Information
| Provider Information | |||||||||
| NPI: | 1780653592 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOTTARDI | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MSCCC/SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 714 BROUGHAM RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283110306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104886844 | ||||||||
| FaxNumber: | 9104886844 | ||||||||
| Practice Location | |||||||||
| Address1: | 2817 REILLY RD | ||||||||
| Address2: | WOMACK ARMY MEDICAL CENTER | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109077332 | ||||||||
| FaxNumber: | 9109078485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 153 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 153 | 01 | NC | LICENSE NUMBER | OTHER |