Healthcare Provider Details

I. General information

NPI: 1629943097
Provider Name (Legal Business Name): ANASTASIA GUDGEON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2025
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 461407
GARLAND TX
75046-1407
US

IV. Provider business mailing address

PO BOX 461407
GARLAND TX
75046-1407
US

V. Phone/Fax

Practice location:
  • Phone: 972-487-4415
  • Fax:
Mailing address:
  • Phone: 972-487-4415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number123995
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: