Provider Demographics
NPI:1770506560
Name:MUNDIS, HEATHER (MA, LP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MUNDIS
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:THORPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LP
Mailing Address - Street 1:7066 STILLWATER BLVD N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3937
Mailing Address - Country:US
Mailing Address - Phone:651-777-5222
Mailing Address - Fax:651-251-5111
Practice Address - Street 1:7066 STILLWATER BLVD N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-3937
Practice Address - Country:US
Practice Address - Phone:651-777-5222
Practice Address - Fax:651-251-5111
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3818103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1029853OtherP1
MN250068OtherCP
MN62-77559OtherUBH
MN025M2THOtherBCBS
MN142660OtherUC