Provider Demographics
NPI:1629133996
Name:AMUNDSON, GARTH W (PSYD)
Entity type:Individual
Prefix:DR
First Name:GARTH
Middle Name:W
Last Name:AMUNDSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 LAKE ST STE 110
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1106
Mailing Address - Country:US
Mailing Address - Phone:708-416-6475
Mailing Address - Fax:
Practice Address - Street 1:1010 LAKE ST STE 110
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1106
Practice Address - Country:US
Practice Address - Phone:708-416-6475
Practice Address - Fax:855-625-7406
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6307103TC0700X
IL071005077103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNLP6307OtherSTATE OF MINNESOTA BOARD OF PSYCHOLOGY