Provider Demographics
NPI:1649424003
Name:MUNDON, CHANDRA (PSYD)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:
Last Name:MUNDON
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 1:2244 NE COUCH ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:917 SW OAK ST STE 407B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2838
Practice Address - Country:US
Practice Address - Phone:510-229-8541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-12
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60795371103TC0700X
OR2544103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical