Provider Demographics
NPI:1336406321
Name:GUNBERG, EDWIN WOODROW (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:WOODROW
Last Name:GUNBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 524
Mailing Address - Street 2:
Mailing Address - City:ROUND HILL
Mailing Address - State:VA
Mailing Address - Zip Code:20142-0524
Mailing Address - Country:US
Mailing Address - Phone:703-915-0326
Mailing Address - Fax:
Practice Address - Street 1:8140 ASHTON AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-5698
Practice Address - Country:US
Practice Address - Phone:703-915-0326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001224101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health