Provider Demographics
NPI:1144778531
Name:GUNDERSON, LAURA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 JAMESON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-1448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2395 ARIEL ST N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2248
Practice Address - Country:US
Practice Address - Phone:651-773-3208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9630235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9630OtherMINNESOTA SPEECH-LANGUAGE PATHOLOGIST LICENSE