Healthcare Provider Details

I. General information

NPI: 1952557126
Provider Name (Legal Business Name): HEATHER GUNDERSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3490 LEXINGTON AVE N
SHOREVIEW MN
55126-8074
US

IV. Provider business mailing address

6425 NICOLLET AVE
RICHFIELD MN
55423-1675
US

V. Phone/Fax

Practice location:
  • Phone: 651-486-3808
  • Fax: 651-486-3858
Mailing address:
  • Phone: 612-861-1675
  • Fax: 612-861-3446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17529
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: