Provider Demographics
NPI:1750622742
Name:GUNDERSON, MARC B (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARC
Middle Name:B
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6754 S SIENA PARK LN
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-5036
Mailing Address - Country:US
Mailing Address - Phone:385-282-5125
Mailing Address - Fax:801-990-4601
Practice Address - Street 1:222 S MAIN ST
Practice Address - Street 2:SUITE 500
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2174
Practice Address - Country:US
Practice Address - Phone:385-282-5125
Practice Address - Fax:801-990-4601
Is Sole Proprietor?:No
Enumeration Date:2013-03-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT345046-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical