Provider Demographics
NPI:1598967705
Name:MUNDT, ALISA MATTESON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALISA
Middle Name:MATTESON
Last Name:MUNDT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 925
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3463
Mailing Address - Country:US
Mailing Address - Phone:312-540-8977
Mailing Address - Fax:
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:SUITE 925
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3463
Practice Address - Country:US
Practice Address - Phone:312-540-8977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007178103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical