Provider Demographics
NPI:1699406777
Name:GUNDRUM, CHRISTA BETH
Entity Type:Individual
Prefix:
First Name:CHRISTA
Middle Name:BETH
Last Name:GUNDRUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 NORTHRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1025
Mailing Address - Country:US
Mailing Address - Phone:262-707-6539
Mailing Address - Fax:
Practice Address - Street 1:15 NORTHRIDGE ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-1025
Practice Address - Country:US
Practice Address - Phone:262-707-6539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health