Provider Demographics
NPI:1982627535
Name:BUNDY, RANDALL EARL (LP)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:EARL
Last Name:BUNDY
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ULM
Mailing Address - State:MN
Mailing Address - Zip Code:56073-3715
Mailing Address - Country:US
Mailing Address - Phone:507-354-3181
Mailing Address - Fax:507-354-3183
Practice Address - Street 1:1407 S STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ULM
Practice Address - State:MN
Practice Address - Zip Code:56073
Practice Address - Country:US
Practice Address - Phone:507-354-3181
Practice Address - Fax:507-354-3183
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2018-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
MNLP1021103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN122361OtherUCARE
MN150226OtherUCARE
MN8441161OtherUBH/MEDICA
MN230222500Medicaid
MN45396BUOtherBCBS
MN84722OtherHEALTH PARTNERS