Healthcare Provider Details

I. General information

NPI: 1316226590
Provider Name (Legal Business Name): AMY B GONSHAK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 08/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4031 FIRESTONE WAY
SHELBYVILLE KY
40065-6305
US

IV. Provider business mailing address

4031 FIRESTONE WAY
SHELBYVILLE KY
40065-6305
US

V. Phone/Fax

Practice location:
  • Phone: 502-523-1863
  • Fax:
Mailing address:
  • Phone: 502-523-1863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: