Healthcare Provider Details

I. General information

NPI: 1720623648
Provider Name (Legal Business Name): MICHELLE GUNDERSON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N 35TH AVE STE 525
HOLLYWOOD FL
33021-5431
US

IV. Provider business mailing address

1150 N 35TH AVE STE 525
HOLLYWOOD FL
33021-5431
US

V. Phone/Fax

Practice location:
  • Phone: 954-265-6968
  • Fax:
Mailing address:
  • Phone: 954-265-6968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY10630
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: