Provider Demographics
NPI:1710302005
Name:GUNDRY, MARK (LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GUNDRY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 SE 11TH AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2411
Mailing Address - Country:US
Mailing Address - Phone:503-957-3391
Mailing Address - Fax:
Practice Address - Street 1:511 SE 11TH AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2411
Practice Address - Country:US
Practice Address - Phone:503-957-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3340101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional