Active NPI
Matthew Frederick Gundlach, EDD
- Counseling Psychologist
- Minnetonka, MN
National Provider Identifier
1295898666
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Counseling Psychologist
- License
- LP1055
- Practice address
- 12450 Wayzata Blvd
Suite 205
Minnetonka, MN 55305-1978 - Phone
- (952) 545-0110
- NPI assigned
- Dec 18, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Counseling Psychologist | 103TC1900X | LP1055 | MN | Primary |
Addresses
Primary practice location
12450 Wayzata Blvd
Suite 205
Minnetonka, MN 55305-1978
Mailing address
12450 Wayzata Blvd
Suite 205
Minnetonka, MN 55305-1978
Phone (952) 545-0110
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MN
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20070219000310 | MN | Practitioner - Clinical Psychologist | 5395847594 | Practice locations: St Louis Park, MN |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LP1055 | MN | MD | Counseling Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1166400000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1295898666",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12450 WAYZATA BLVD",
"address_2": "SUITE 205",
"city": "MINNETONKA",
"state": "MN",
"postal_code": "553051978",
"telephone_number": "952-545-0110"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12450 WAYZATA BLVD",
"address_2": "SUITE 205",
"city": "MINNETONKA",
"state": "MN",
"postal_code": "553051978",
"telephone_number": "952-545-0110"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GUNDLACH",
"first_name": "MATTHEW",
"middle_name": "FREDERICK",
"name_prefix": "Dr.",
"credential": "EDD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-12-18",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC1900X",
"taxonomy_group": "",
"desc": "Psychologist, Counseling",
"state": "MN",
"license": "LP1055",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Minnetonka, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.