Provider Demographics
NPI:1710106257
Name:MUNDA, KELLEY (MSED, NCC, LCPC)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:MUNDA
Suffix:
Gender:F
Credentials:MSED, NCC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 N WHISTLER AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4069
Mailing Address - Country:US
Mailing Address - Phone:815-235-6171
Mailing Address - Fax:815-235-6172
Practice Address - Street 1:34 N WHISTLER AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4069
Practice Address - Country:US
Practice Address - Phone:815-235-6171
Practice Address - Fax:815-235-6172
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional