Provider Demographics
NPI:1063023711
Name:SUNDANO-SECRESTY, MUCHALA
Entity Type:Individual
Prefix:
First Name:MUCHALA
Middle Name:
Last Name:SUNDANO-SECRESTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 W MERRY AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 W STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH BALTIMORE
Practice Address - State:OH
Practice Address - Zip Code:45872-1332
Practice Address - Country:US
Practice Address - Phone:567-806-4808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2005231104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker