Provider Demographics
NPI:1063051373
Name:GOLDEN, GUNNER (LAC)
Entity type:Individual
Prefix:
First Name:GUNNER
Middle Name:
Last Name:GOLDEN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10025 W. MARKHAM STREET
Mailing Address - Street 2:STE 210
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-2178
Mailing Address - Country:US
Mailing Address - Phone:501-663-5473
Mailing Address - Fax:501-801-1816
Practice Address - Street 1:3604 CENTRAL AVENUE
Practice Address - Street 2:STE C
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913
Practice Address - Country:US
Practice Address - Phone:501-623-9220
Practice Address - Fax:501-623-9227
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
ARA2310024101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR237779795Medicaid