Provider Demographics
NPI:1043081771
Name:MUNDT, ANDREA (MS, LCAT, ATR-BC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MUNDT
Suffix:
Gender:F
Credentials:MS, LCAT, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 REDMAN RD
Mailing Address - Street 2:
Mailing Address - City:HAMLIN
Mailing Address - State:NY
Mailing Address - Zip Code:14464-9606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4107 LAKE RD N
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1519
Practice Address - Country:US
Practice Address - Phone:585-454-9338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002379221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist