Provider Demographics
NPI:1447822861
Name:GUNDERMAN, TAYLOR NICOLE (LMT)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
Last Name:GUNDERMAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5172 SW SLAVIN RD APT 69
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-8213
Mailing Address - Country:US
Mailing Address - Phone:847-863-8287
Mailing Address - Fax:
Practice Address - Street 1:3821 NE MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-1114
Practice Address - Country:US
Practice Address - Phone:503-289-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26400225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist