Provider Demographics
NPI:1710487947
Name:GUNDERSON ECCLESTON, KATHERINE ELYSE (MS, LPCC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELYSE
Last Name:GUNDERSON ECCLESTON
Suffix:
Gender:F
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3306 BUCHANAN ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-1450
Mailing Address - Country:US
Mailing Address - Phone:612-481-2110
Mailing Address - Fax:
Practice Address - Street 1:7954 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-1860
Practice Address - Country:US
Practice Address - Phone:763-780-3036
Practice Address - Fax:763-780-0784
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1741101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional