Provider Demographics
NPI:1356490080
Name:MUNGADZE, JERRY J (PHD, LPC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:J
Last Name:MUNGADZE
Suffix:
Gender:M
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 BEDFORD RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-5871
Mailing Address - Country:US
Mailing Address - Phone:817-354-1389
Mailing Address - Fax:
Practice Address - Street 1:2040 BEDFORD RD STE 200
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-5871
Practice Address - Country:US
Practice Address - Phone:817-354-1389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10315101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7323LCOtherBLUECROSS BLUE SHIELD