Basic Information
Provider Information | |||||||||
NPI: | 1104880327 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUNDERSON | ||||||||
FirstName: | ROBYN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 43 | ||||||||
Address2: | MR 10809 | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554400043 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6122624813 | ||||||||
FaxNumber: | 6122624194 | ||||||||
Practice Location | |||||||||
Address1: | 680 PROFESSIONAL DR | ||||||||
Address2: |   | ||||||||
City: | NORTHFIELD | ||||||||
State: | MN | ||||||||
PostalCode: | 550572755 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5076630237 | ||||||||
FaxNumber: | 5076631180 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2006 | ||||||||
LastUpdateDate: | 03/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2032 | CO | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103T00000X | 071-004153 | IL | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103T00000X | LP4256 | MN | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 679487400 | 05 | MN |   | MEDICAID |