Provider Demographics
NPI:1295967776
Name:MUNDORF, GWEN (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:MUNDORF
Suffix:
Gender:
Credentials:MSW, LCSW
Other - Prefix:MS
Other - First Name:GWEN
Other - Middle Name:ANN
Other - Last Name:MUNDORF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:5800 N COURTENAY PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-7241
Mailing Address - Country:US
Mailing Address - Phone:321-615-1451
Mailing Address - Fax:888-341-8272
Practice Address - Street 1:3270 SUNTREE BLVD STE 207
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7505
Practice Address - Country:US
Practice Address - Phone:321-615-0990
Practice Address - Fax:888-341-8272
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 107361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical