Provider Demographics
NPI:1639157316
Name:BUNDY, MIRIAM P (LPC, CEAP)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:P
Last Name:BUNDY
Suffix:
Gender:F
Credentials:LPC, CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 PARK RD
Mailing Address - Street 2:SUITE 119
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3650
Mailing Address - Country:US
Mailing Address - Phone:704-527-5300
Mailing Address - Fax:704-527-5302
Practice Address - Street 1:5200 PARK RD
Practice Address - Street 2:SUITE 119
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3650
Practice Address - Country:US
Practice Address - Phone:704-527-5300
Practice Address - Fax:704-527-5302
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2417101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional