Provider Demographics
NPI:1447869276
Name:GUDMUNDSON, LAURA SUE (CSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:SUE
Last Name:GUDMUNDSON
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 E 4500 S STE 360
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3920
Mailing Address - Country:US
Mailing Address - Phone:801-440-7879
Mailing Address - Fax:
Practice Address - Street 1:348 E 4500 S STE 360
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3920
Practice Address - Country:US
Practice Address - Phone:801-440-7879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5532544-35061041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool