Provider Demographics
NPI:1669204681
Name:MUNDY, LORI
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:MUNDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 WHITFORD AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2824
Mailing Address - Country:US
Mailing Address - Phone:973-393-0099
Mailing Address - Fax:
Practice Address - Street 1:169 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-2311
Practice Address - Country:US
Practice Address - Phone:973-667-1884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00719600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health