Provider Demographics
NPI:1215570361
Name:MUNDT, PAIGE ALEXANDRIA (PTA)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:ALEXANDRIA
Last Name:MUNDT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6063 FM 841
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-4639
Mailing Address - Country:US
Mailing Address - Phone:936-240-3770
Mailing Address - Fax:
Practice Address - Street 1:900 S TEMPLE DR
Practice Address - Street 2:
Practice Address - City:DIBOLL
Practice Address - State:TX
Practice Address - Zip Code:75941-2725
Practice Address - Country:US
Practice Address - Phone:936-829-5501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2147682225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant