Provider Demographics
NPI:1336454412
Name:GUNDERSON, KEVIN S (MSE)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:S
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 STUART ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4313
Mailing Address - Country:US
Mailing Address - Phone:920-437-1027
Mailing Address - Fax:
Practice Address - Street 1:2745 BAYLITE DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-7173
Practice Address - Country:US
Practice Address - Phone:920-362-2152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI887-226101YP2500X
WI5011-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100029719Medicaid