Provider Demographics
NPI:1194249268
Name:GULLBERG, MIRANDA J (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:J
Last Name:GULLBERG
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:J
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:1514 US ROUTE 34
Mailing Address - Street 2:
Mailing Address - City:BIGGSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61418-5012
Mailing Address - Country:US
Mailing Address - Phone:309-627-2339
Mailing Address - Fax:
Practice Address - Street 1:1514 US ROUTE 34
Practice Address - Street 2:
Practice Address - City:BIGGSVILLE
Practice Address - State:IL
Practice Address - Zip Code:61418-5012
Practice Address - Country:US
Practice Address - Phone:309-627-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146012643235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist