1306474036 NPI number — NATASHA MARIE GUNDERSON LADC, LPCC

Table of content: UTKARSH S PATEL PT (NPI 1588948145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306474036 NPI number — NATASHA MARIE GUNDERSON LADC, LPCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUNDERSON
Provider First Name:
NATASHA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LADC, LPCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PRANGE
Provider Other First Name:
NATASHA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306474036
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6043 HUDSON RD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125-1019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-348-5594
Provider Business Mailing Address Fax Number:
651-925-8201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6043 HUDSON RD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-1019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-348-5594
Provider Business Practice Location Address Fax Number:
651-925-8201
Provider Enumeration Date:
03/30/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  2377 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , with the licence number: 304953 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)