Provider Demographics
NPI:1164636668
Name:WUNDERLICH, RICHARD CRAIG (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:CRAIG
Last Name:WUNDERLICH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 N CAMINO DE VIS
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-9797
Mailing Address - Country:US
Mailing Address - Phone:520-743-4558
Mailing Address - Fax:
Practice Address - Street 1:2001 W STARR PASS BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-1303
Practice Address - Country:US
Practice Address - Phone:520-225-4022
Practice Address - Fax:520-225-4001
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW - 1088104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ630873Medicaid