Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | LP2801 | MN |
NPI | 1093835159 |
---|---|
Provider Name | Dr. Gary Edwin Gunderson |
First Address | Pequot Lakes, MN 56472-3312 |
Second Address | Brainerd, MN 56401-3997 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1012381 | PR ONE (01) | MN |
150743 | BHP (01) | MN |
25543 | HP (01) | MN |
4K588GU | BCBS (01) | MN |
62-47591 | UBH (01) | MN |