Basic Information
Provider Information | |||||||||
NPI: | 1124090642 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUNDERSON | ||||||||
FirstName: | BEVERLY | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ED.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 86370 | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571186370 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053227510 | ||||||||
FaxNumber: | 6053226475 | ||||||||
Practice Location | |||||||||
Address1: | 4400 W 69TH ST | ||||||||
Address2: | STE 1500 | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571088170 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053225700 | ||||||||
FaxNumber: | 6053225704 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2006 | ||||||||
LastUpdateDate: | 10/11/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 195 | SD | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
ID | Type | State | Issuer | Description | 680015878 | 01 | SD | RR MEDICARE | OTHER | P195 | 01 | SD | DAKOTACARE | OTHER | 12200 | 05 | ND |   | MEDICAID | 412991028090 | 01 | SD | PREFERRED ONE | OTHER | 581816800 | 05 | MN |   | MEDICAID | 596332 | 01 | SD | ARAZ/ AMERICA'S PPO | OTHER | 040121002 | 01 | MN | PRIMEWEST | OTHER | 10635 | 01 | SD | MIDLANDS CHOICE | OTHER | 57108C025 | 01 | SD | WPS TRICARE | OTHER | 46022474352 | 05 | NE |   | MEDICAID | 0040485 | 01 | SD | BLUE CROSS | OTHER | 141M3GU | 01 | MN | CC SYSTEMS/ BLUE PLUS | OTHER | 3989442 | 05 | IA |   | MEDICAID | 122288 | 01 | MN | UCARE | OTHER | 28142 | 01 | SD | SANFORD HEALTH PLAN | OTHER | HP24855 | 01 | SD | HEALTPARTNERS | OTHER | 6550806 | 05 | SD |   | MEDICAID |