Provider Demographics
NPI:1376686337
Name:GUNDERSON, KELLY RILEY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:RILEY
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458-1709
Mailing Address - Country:US
Mailing Address - Phone:617-558-3681
Mailing Address - Fax:
Practice Address - Street 1:1234 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-1703
Practice Address - Country:US
Practice Address - Phone:617-855-3986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8523103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist