Healthcare Provider Details

I. General information

NPI: 1497999650
Provider Name (Legal Business Name): PATRICIA ANN GUNDRUM MSW,LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PATRICIA ANN GUNDRUM MSW,LMSW

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3493 WOODS EDGE SUITE 103
OKEMOS MI
48864-5911
US

IV. Provider business mailing address

PO BOX 43
MASON MI
48854-0043
US

V. Phone/Fax

Practice location:
  • Phone: 517-886-3707
  • Fax: 517-349-1973
Mailing address:
  • Phone: 517-623-6260
  • Fax: 517-623-6460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6801073024
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: