Healthcare Provider Details

I. General information

NPI: 1750682720
Provider Name (Legal Business Name): KELLY GUNDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 GREEN BAY RD
NORTH CHICAGO IL
60064-3048
US

IV. Provider business mailing address

3001 GREEN BAY RD
NORTH CHICAGO IL
60064-3048
US

V. Phone/Fax

Practice location:
  • Phone: 224-610-4154
  • Fax: 224-610-3706
Mailing address:
  • Phone: 224-610-4154
  • Fax: 224-610-3706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4393-046
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: