MEDICARE: KAITLIN ELIZABETH GUNDERSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	258401	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	258401	OTHER	KY	LCSW

General Provider Information

NPI Number	:	1104604057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLIN ELIZABETH GUNDERSON LCSW

Provider Business Mailing Address
First Line	:	5000 BACK SQUARE DR STE D
Second Line	:
City	:	OWENSBORO
State	:	KY
Zip	:	42301-7411
Country	:	US
Telephone Number	:	270-685-5500
Fax Number	:

Provider Business Practice Location Address
First Line	:	5000 BACK SQUARE DR STE D
Second Line	:
City	:	OWENSBORO
State	:	KY
Zip	:	42301-7411
Country	:	US
Telephone Number	:	270-685-5500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2023
Last Update Date	:	09/20/2023

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