Basic Information
Provider Information | |||||||||
NPI: | 1053495721 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUNTER | ||||||||
FirstName: | MONICA | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1640 FORT ST | ||||||||
Address2: | SUITE D ATTN DENISE | ||||||||
City: | TRENTON | ||||||||
State: | MI | ||||||||
PostalCode: | 481832040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7343913057 | ||||||||
FaxNumber: | 7343913052 | ||||||||
Practice Location | |||||||||
Address1: | 2333 BIDDLE ST | ||||||||
Address2: |   | ||||||||
City: | WYANDOTTE | ||||||||
State: | MI | ||||||||
PostalCode: | 481924668 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7342466000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2006 | ||||||||
LastUpdateDate: | 03/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301008752 | MI | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 6301008752 | 01 | MI | LICENSE | OTHER | 680H247960 | 01 |   | BLUE SHIELD # | OTHER | 0H21780 | 01 | MI | BLUE CROSS # HENRY FORD WYANDOTTE | OTHER | 1467687640 | 01 |   | GROUP NPI HENRY FORD WYANDOTTE | OTHER |