Provider Demographics
NPI:1669025276
Name:NGUNDAM, PHILIP NGU (MBA)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:NGU
Last Name:NGUNDAM
Suffix:
Gender:M
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14302 PLEASANT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4809
Mailing Address - Country:US
Mailing Address - Phone:240-398-0992
Mailing Address - Fax:301-273-1006
Practice Address - Street 1:14302 PLEASANT VIEW DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-4809
Practice Address - Country:US
Practice Address - Phone:240-398-0992
Practice Address - Fax:301-273-1006
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health