Provider Demographics
NPI:1790110583
Name:HARDAGE-BUNDY, ANGIE (MA, LMLP)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:HARDAGE-BUNDY
Suffix:
Gender:F
Credentials:MA, LMLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 N GATEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-4009
Mailing Address - Country:US
Mailing Address - Phone:316-640-1557
Mailing Address - Fax:316-636-4522
Practice Address - Street 1:10500 E BERKELEY SQUARE PKWY
Practice Address - Street 2:SUITE 103
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-6815
Practice Address - Country:US
Practice Address - Phone:316-640-1557
Practice Address - Fax:316-636-4522
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2355103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical