Basic Information
| Provider Information | |||||||||
| NPI: | 1770506560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUNDIS | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., LP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THORPE | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.A., LP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7066 STILLWATER BLVD N | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551283937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517775222 | ||||||||
| FaxNumber: | 6512515111 | ||||||||
| Practice Location | |||||||||
| Address1: | 7066 STILLWATER BLVD N | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551283937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517775222 | ||||||||
| FaxNumber: | 6512515111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 08/27/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 3818 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 1029853 | 01 | MN | P1 | OTHER | 250068 | 01 | MN | CP | OTHER | 62-77559 | 01 | MN | UBH | OTHER | 025M2TH | 01 | MN | BCBS | OTHER | 142660 | 01 | MN | UC | OTHER |