Provider Demographics
NPI:1689835068
Name:SUND, SALLY JO (MED LMHC)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:JO
Last Name:SUND
Suffix:
Gender:F
Credentials:MED LMHC
Other - Prefix:MRS
Other - First Name:SALLY
Other - Middle Name:JO
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:3525 ENSIGN RD NE
Mailing Address - Street 2:MEDICAL RESOURCE CENTER SUITE G
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506
Mailing Address - Country:US
Mailing Address - Phone:360-456-2177
Mailing Address - Fax:360-877-9603
Practice Address - Street 1:3525 ENSIGN RD NE
Practice Address - Street 2:MEDICAL RESOURCE CENTER SUITE G
Practice Address - City:OLY
Practice Address - State:WA
Practice Address - Zip Code:98506
Practice Address - Country:US
Practice Address - Phone:360-456-2177
Practice Address - Fax:360-877-9603
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00003924101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health