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General NPI Number Information
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NPI Number | 1295898666
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Entity Type | Individual
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Provider Name | MATTHEW FREDERICK GUNDLACH EDD
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Gender | Male
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 12450 WAYZATA BLVD SUITE 205
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City | MINNETONKA
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State | MN
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Zip | 55305-1978
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Country | US
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Telephone | 952-545-0110
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Fax |
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Provider Business Mailing Address
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Address Line | 12450 WAYZATA BLVD SUITE 205
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City | MINNETONKA
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State | MN
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Zip | 55305-1978
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Country | US
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Telephone | 952-545-0110
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | LP1055
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License Number State | MN
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