=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790280170
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GUNDERKLINE COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2018
-----------------------------------------------------
Last Update Date | 03/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4753 N BROADWAY ST STE 928
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-7911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-206-7171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4753 N BROADWAY ST STE 928
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-7911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-206-7171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER THERAPIST
-----------------------------------------------------
Name | EVE GUNDERKLINE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 937-206-7171
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 149.017384
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------