Provider Demographics
NPI:1043298060
Name:GUNDERSON, THERESA L (PHD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 ZANE AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-1814
Mailing Address - Country:US
Mailing Address - Phone:763-762-8800
Mailing Address - Fax:
Practice Address - Street 1:111 HUNDERTMARK RD STE 205N
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1586
Practice Address - Country:US
Practice Address - Phone:952-903-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4545103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN938S8GUOtherBCBS
MNHP49455OtherHEALTH PARTNERS
MN2316538OtherAMERICAS PPO
680016226OtherRR MEDICARE
MN104336OtherUCARE
MN332159200Medicaid
410849339560015008OtherCHAMPUS
MNNA2951042871OtherPREFFERED ONE