Provider Demographics
NPI:1083047211
Name:GUNNERSON, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:GUNNERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2405
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-2405
Mailing Address - Country:US
Mailing Address - Phone:912-225-6920
Mailing Address - Fax:
Practice Address - Street 1:132 RALEIGH CT
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0160
Practice Address - Country:US
Practice Address - Phone:912-225-6920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2024-07-31
Deactivation Date:2022-09-14
Deactivation Code:
Reactivation Date:2024-07-30
Provider Licenses
StateLicense IDTaxonomies
GAPSY004627103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling