Provider Demographics
NPI:1093957912
Name:MUNDRICK, WARREN J (OT)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:J
Last Name:MUNDRICK
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 BLEECKER ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501
Mailing Address - Country:US
Mailing Address - Phone:315-798-4867
Mailing Address - Fax:315-798-4944
Practice Address - Street 1:2150 BLEECKER ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-1738
Practice Address - Country:US
Practice Address - Phone:315-798-4867
Practice Address - Fax:315-798-4944
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004081-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY004081-1OtherLICENSE