Provider Demographics
NPI:1326409632
Name:MUNDEY, MARISA SUZANN
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:SUZANN
Last Name:MUNDEY
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 1:11211 KATY FWY
Mailing Address - Street 2:SUITE 440E
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-2126
Mailing Address - Country:US
Mailing Address - Phone:713-249-4960
Mailing Address - Fax:
Practice Address - Street 1:11211 KATY FWY
Practice Address - Street 2:SUITE 440E
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-2126
Practice Address - Country:US
Practice Address - Phone:713-249-4960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201375106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist