Provider Demographics
NPI:1073097077
Name:MUNDY, MITCHELL (LAPC APC006606)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:MUNDY
Suffix:
Gender:M
Credentials:LAPC APC006606
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 PARKVIEW LN NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-1211
Mailing Address - Country:US
Mailing Address - Phone:937-344-5564
Mailing Address - Fax:
Practice Address - Street 1:1328 PEACHTREE ST NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-3209
Practice Address - Country:US
Practice Address - Phone:937-344-5564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006606101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty