Provider Demographics
NPI:1710278502
Name:SUNDBY, MARK ELMER (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ELMER
Last Name:SUNDBY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 MISSION HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-2571
Mailing Address - Country:US
Mailing Address - Phone:651-636-5120
Mailing Address - Fax:651-636-5124
Practice Address - Street 1:516 MISSION HOUSE LN
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-2571
Practice Address - Country:US
Practice Address - Phone:651-636-5120
Practice Address - Fax:651-636-5124
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4114103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling