Provider Demographics
NPI:1619348281
Name:LUNDERGAN, MARY CELESTE (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CELESTE
Last Name:LUNDERGAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 SE ATHENS DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-1069
Mailing Address - Country:US
Mailing Address - Phone:816-500-5936
Mailing Address - Fax:
Practice Address - Street 1:1278 W US HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:MO
Practice Address - Zip Code:64076-9612
Practice Address - Country:US
Practice Address - Phone:844-853-8937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-08
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024014514101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional