Provider Demographics
NPI:1477508760
Name:GUNDERSON, BRANDIS L (PT)
Entity Type:Individual
Prefix:
First Name:BRANDIS
Middle Name:L
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 GRANARY AVE
Mailing Address - Street 2:# 3
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-3089
Mailing Address - Country:US
Mailing Address - Phone:360-318-5478
Mailing Address - Fax:360-485-0505
Practice Address - Street 1:1211 GRANARY AVE
Practice Address - Street 2:# 3
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-3089
Practice Address - Country:US
Practice Address - Phone:360-318-5478
Practice Address - Fax:360-485-0505
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60244355225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40473700Medicaid