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General NPI Number Information
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NPI Number | 1336454412
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Entity Type | Individual
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Provider Name | KEVIN S GUNDERSON M.S.E.
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Gender | Male
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Dates
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Enumeration Date | 08/12/2010
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Last Update Date | 09/14/2021
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Provider Practice Location Address
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Address Line | 2745 BAYLITE DR
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City | GREEN BAY
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State | WI
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Zip | 54313-7173
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Country | US
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Telephone | 920-362-2152
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Fax |
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Provider Business Mailing Address
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Address Line | 1220 STUART ST
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City | GREEN BAY
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State | WI
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Zip | 54301-4313
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Country | US
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Telephone | 920-437-1027
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 887-226
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 5011-125
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License Number State | WI
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