Basic Information
| Provider Information | |||||||||
| NPI: | 1902985625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUNDY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW, ACSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1044 N FLORENCE AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741105121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186408575 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3507 E ADMIRAL PL | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741158211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188344194 | ||||||||
| FaxNumber: | 9188344189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 1041C0700X | 1041C0700X | OK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1275 | 01 | OK | CLINICAL SOCIAL WORK LIC. | OTHER |