Healthcare Provider Details

I. General information

NPI: 1043298060
Provider Name (Legal Business Name): THERESA L GUNDERSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HUNDERTMARK RD STE 205N
CHASKA MN
55318-1586
US

IV. Provider business mailing address

9400 ZANE AVE N
BROOKLYN PARK MN
55443-1814
US

V. Phone/Fax

Practice location:
  • Phone: 952-903-1370
  • Fax:
Mailing address:
  • Phone: 763-762-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP4545
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: