Provider Demographics
NPI:1760036784
Name:MONDIE, JUNIOR
Entity Type:Individual
Prefix:
First Name:JUNIOR
Middle Name:
Last Name:MONDIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 114
Mailing Address - Street 2:
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642-0114
Mailing Address - Country:US
Mailing Address - Phone:606-872-0578
Mailing Address - Fax:
Practice Address - Street 1:321 RINGGOLD RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3900
Practice Address - Country:US
Practice Address - Phone:606-451-1936
Practice Address - Fax:606-451-9713
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY248054101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional