Provider Demographics
NPI:1487204947
Name:MUNDELL, CATHERINE JANE (LPC, CRC)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:JANE
Last Name:MUNDELL
Suffix:
Gender:F
Credentials:LPC, CRC
Other - Prefix:
Other - First Name:CATHY
Other - Middle Name:
Other - Last Name:MUNDELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:BOVILL
Mailing Address - State:ID
Mailing Address - Zip Code:83806-0523
Mailing Address - Country:US
Mailing Address - Phone:208-816-3078
Mailing Address - Fax:
Practice Address - Street 1:106 E 3RD ST STE 3B
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2970
Practice Address - Country:US
Practice Address - Phone:509-592-8268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-7721101YP2500X, 101YP2500X
ID7721101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor