Healthcare Provider Details

I. General information

NPI: 1508664269
Provider Name (Legal Business Name): JOAN GUDORF LICSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4530 77TH ST W STE 325
EDINA MN
55435-5012
US

IV. Provider business mailing address

4808 WILFORD WAY
EDINA MN
55435-1563
US

V. Phone/Fax

Practice location:
  • Phone: 612-554-5095
  • Fax:
Mailing address:
  • Phone: 612-554-5095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JOAN GUDORF
Title or Position: OWNER/LICENSED SOCIAL WORKER
Credential: LICSW
Phone: 612-555-5095