Basic Information
| Provider Information | |||||||||
| NPI: | 1780660951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUNTHER | ||||||||
| FirstName: | MAIDA | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2828 CHICAGO AVE | ||||||||
| Address2: | SUITE #200 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128791000 | ||||||||
| FaxNumber: | 6128799116 | ||||||||
| Practice Location | |||||||||
| Address1: | 2828 CHICAGO AVE | ||||||||
| Address2: | SUITE #200 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128791000 | ||||||||
| FaxNumber: | 6128799116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 10/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | LP3565 | MN | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | LP3565 | MN | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | LP3565 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 392G5GU | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 482415600 | 05 | MN | MEDICAID | 61-78167 | 01 | MN | UNITED BEHAVIORAL HEALTH | OTHER |