1003441320 NPI number — CHRISTINE SIMONE GUNDERSON SCHOOL PSYCHOLOGIST

Table of content: CHRISTINE SIMONE GUNDERSON SCHOOL PSYCHOLOGIST (NPI 1003441320)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003441320 NPI number — CHRISTINE SIMONE GUNDERSON SCHOOL PSYCHOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
GUNDERSON

Provider First Name:
CHRISTINE

Provider Middle Name:
SIMONE

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
SCHOOL PSYCHOLOGIST

Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:
MERRILL

Provider Other First Name:
CHRISTINE

Provider Other Middle Name:
SIMONE

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:
SCHOOL PSYCHOLOGIST

Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003441320

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
03/06/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
UNIT 3370 BOX 42

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
DPO

Provider Business Mailing Address State Name:
AA

Provider Business Mailing Address Postal Code:
34011-0042

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
949-200-7115

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42 QUEEN STREET

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
NASSAU

Provider Business Practice Location Address State Name:
NEW PROVIDENCE

Provider Business Practice Location Address Postal Code:
00000

Provider Business Practice Location Address Country Code:
BS

Provider Business Practice Location Address Telephone Number:
949-200-7115

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
03/06/2020

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: 103TS0200X , with the licence number: 160071453 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .