Provider Demographics
NPI:1700418332
Name:GUNDERSON, CAROL ELIZABETH (LASAC)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ELIZABETH
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:LASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 N 18TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-3037
Mailing Address - Country:US
Mailing Address - Phone:602-206-6784
Mailing Address - Fax:
Practice Address - Street 1:5010 E SHEA BLVD STE D202
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4570
Practice Address - Country:US
Practice Address - Phone:602-569-4328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLASAC-15120101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)