Provider Demographics
NPI:1497999650
Name:GUNDRUM, PATRICIA ANN (MSW,LMSW)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:ANN
Last Name:GUNDRUM
Suffix:
Gender:F
Credentials:MSW,LMSW
Other - Prefix:MRS
Other - First Name:PATRICIA
Other - Middle Name:ANN
Other - Last Name:GUNDRUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW,LMSW
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0043
Mailing Address - Country:US
Mailing Address - Phone:517-623-6260
Mailing Address - Fax:517-623-6460
Practice Address - Street 1:3493 WOODS EDGE
Practice Address - Street 2:SUITE 103
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-5911
Practice Address - Country:US
Practice Address - Phone:517-886-3707
Practice Address - Fax:517-349-1973
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-30
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801073024101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI800313060OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIP40800012Medicare PIN