Provider Demographics
NPI:1235637968
Name:VAN GUNDY, DENISE (LISW-S)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:VAN GUNDY
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-0604
Mailing Address - Country:US
Mailing Address - Phone:740-412-4524
Mailing Address - Fax:
Practice Address - Street 1:26442 KIME HOLDERMAN RD
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113
Practice Address - Country:US
Practice Address - Phone:740-412-4524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
OHI.1800977-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker