Provider Demographics
NPI:1508664269
Name:JOAN GUDORF LICSW PLLC
Entity type:Organization
Organization Name:JOAN GUDORF LICSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUDORF
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:612-555-5095
Mailing Address - Street 1:4808 WILFORD WAY
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1563
Mailing Address - Country:US
Mailing Address - Phone:612-554-5095
Mailing Address - Fax:
Practice Address - Street 1:12400 PORTLAND AVE STE 180
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6875
Practice Address - Country:US
Practice Address - Phone:612-554-5095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)