Provider Demographics
NPI:1598036543
Name:GUNDERSON, JUSTIN (LCSW)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N KENNEDY DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1559
Mailing Address - Country:US
Mailing Address - Phone:815-929-2009
Mailing Address - Fax:815-929-1284
Practice Address - Street 1:300 N KENNEDY DR
Practice Address - Street 2:SUITE 8
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1559
Practice Address - Country:US
Practice Address - Phone:815-929-2009
Practice Address - Fax:815-929-1284
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0150531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical