Basic Information
| Provider Information | |||||||||
| NPI: | 1295048585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUNDIGEL | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | CADCI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16141 E BURNSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972333519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032523949 | ||||||||
| FaxNumber: | 5032524027 | ||||||||
| Practice Location | |||||||||
| Address1: | 16141 E BURNSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972333519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032523949 | ||||||||
| FaxNumber: | 5032524027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2010 | ||||||||
| LastUpdateDate: | 07/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CADCI 10-03-25 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.