Basic Information
| Provider Information | |||||||||
| NPI: | 1235776543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUNDERSON | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6120 EARLE BROWN DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN CENTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554304100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157815491 | ||||||||
| FaxNumber: | 7635377162 | ||||||||
| Practice Location | |||||||||
| Address1: | 5384 5TH ST NE | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554211108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635720009 | ||||||||
| FaxNumber: | 7635377162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2019 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.