Provider Demographics
NPI:1932643699
Name:GUNDERSON, CHRISTOPHER JOHN
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JOHN
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 NEWTOWN PIKE
Mailing Address - Street 2:ATTENTION BILLING
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1275
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1351 NEWTOWN PIKE
Practice Address - Street 2:ATTENTION BILLING
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-1275
Practice Address - Country:US
Practice Address - Phone:859-233-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-14
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid