Basic Information
| Provider Information | |||||||||
| NPI: | 1497999650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUNDRUM | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW,LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUNDRUM | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW,LMSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 43 | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488540043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176236260 | ||||||||
| FaxNumber: | 5176236460 | ||||||||
| Practice Location | |||||||||
| Address1: | 3493 WOODS EDGE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488645911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178863707 | ||||||||
| FaxNumber: | 5173491973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2009 | ||||||||
| LastUpdateDate: | 02/09/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6801073024 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 800313060 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN | OTHER |