Provider Demographics
NPI:1386193001
Name:DUNDORE, KRISTINA E (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:E
Last Name:DUNDORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:E
Other - Last Name:RUTKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:320 HIGHLAND DRIVE
Mailing Address - Street 2:PO BOX 597
Mailing Address - City:MOUNTVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17554-0597
Mailing Address - Country:US
Mailing Address - Phone:570-323-6944
Mailing Address - Fax:570-323-4529
Practice Address - Street 1:790 NEW HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2137
Practice Address - Country:US
Practice Address - Phone:717-390-0353
Practice Address - Fax:717-390-1812
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW132765104100000X
PACW0205671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103495942-0001Medicaid