Provider Demographics
NPI:1457002529
Name:SUNDRA, NELL
Entity Type:Individual
Prefix:
First Name:NELL
Middle Name:
Last Name:SUNDRA
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 1:12 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IL
Practice Address - Zip Code:61951-1907
Practice Address - Country:US
Practice Address - Phone:217-728-4358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health