Provider Demographics
NPI:1245306091
Name:MUNDT, ELIZABETH A (PHD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:A
Last Name:MUNDT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 RODMANS LN
Mailing Address - Street 2:
Mailing Address - City:ULSTER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12487-5013
Mailing Address - Country:US
Mailing Address - Phone:845-338-7132
Mailing Address - Fax:845-338-7132
Practice Address - Street 1:4 RODMANS LN
Practice Address - Street 2:
Practice Address - City:ULSTER PARK
Practice Address - State:NY
Practice Address - Zip Code:12487-5013
Practice Address - Country:US
Practice Address - Phone:845-338-7132
Practice Address - Fax:845-338-7132
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011272-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist