Provider Demographics
NPI:1972713220
Name:BUNDY, MYRA BETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:BETH
Last Name:BUNDY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:521 LANCASTER AVE
Mailing Address - Street 2:EKU, DEPARTMENT OF PSYCHOLOGY
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-3100
Mailing Address - Country:US
Mailing Address - Phone:859-622-1105
Mailing Address - Fax:859-622-5817
Practice Address - Street 1:521 LANCASTER AVE
Practice Address - Street 2:EKU, DEPARTMENT OF PSYCHOLOGY
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3100
Practice Address - Country:US
Practice Address - Phone:859-622-1105
Practice Address - Fax:859-622-5817
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-1021103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent