Provider Demographics
NPI:1952474827
Name:MUNDT, DIANE (LICSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MUNDT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3268
Mailing Address - Country:US
Mailing Address - Phone:360-487-6319
Mailing Address - Fax:
Practice Address - Street 1:1101 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3268
Practice Address - Country:US
Practice Address - Phone:360-487-6319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL2490101YM0800X
WALW60104168101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health