Provider Demographics
NPI:1568958239
Name:WUNDERLICH, JOHN PAUL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PAUL
Last Name:WUNDERLICH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 MACKLIND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1440
Mailing Address - Country:US
Mailing Address - Phone:314-881-3487
Mailing Address - Fax:314-534-7996
Practice Address - Street 1:1129 MACKLIND AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1440
Practice Address - Country:US
Practice Address - Phone:314-881-3487
Practice Address - Fax:314-534-7996
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MO2020009163103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor