Healthcare Provider Details

I. General information

NPI: 1275885469
Provider Name (Legal Business Name): CENTER FOR WELLNESS & CHANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1007 E HIGH ST
CHARLOTTESVILLE VA
22902-4841
US

IV. Provider business mailing address

1007 E HIGH ST
CHARLOTTESVILLE VA
22902-4841
US

V. Phone/Fax

Practice location:
  • Phone: 434-202-8612
  • Fax: 434-321-5181
Mailing address:
  • Phone: 434-202-8612
  • Fax: 434-321-5181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101244180
License Number StateVA

VIII. Authorized Official

Name: DR. ERIK WILLIAM GUNDERSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 434-202-8612