Provider Demographics
NPI:1093835159
Name:GUNDERSON, GARY EDWIN (ED D, MS LP)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:EDWIN
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:ED D, MS LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28022 COUNTY ROAD 107
Mailing Address - Street 2:
Mailing Address - City:PEQUOT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56472-3312
Mailing Address - Country:US
Mailing Address - Phone:218-838-2448
Mailing Address - Fax:
Practice Address - Street 1:702 SW 5TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3997
Practice Address - Country:US
Practice Address - Phone:218-454-6369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2801103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1012381OtherPR ONE
MN4K588GUOtherBCBS
MN150743OtherBHP
MN62-47591OtherUBH
MN25543OtherHP