Provider Demographics
NPI:1659658649
Name:BUNDY, TANISHA SONJIA (MSW)
Entity Type:Individual
Prefix:MISS
First Name:TANISHA
Middle Name:SONJIA
Last Name:BUNDY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 WHALLEY AVE APT 158 NEW HAVEN
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511
Mailing Address - Country:US
Mailing Address - Phone:203-214-6409
Mailing Address - Fax:
Practice Address - Street 1:191 WHALLEY AVE APT 158
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3220
Practice Address - Country:US
Practice Address - Phone:203-214-6409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker