1295967776 NPI number — GWEN MUNDORF MSW, LCSW

Table of content: GWEN MUNDORF MSW, LCSW (NPI 1295967776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295967776 NPI number — GWEN MUNDORF MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUNDORF
Provider First Name:
GWEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MUNDORF
Provider Other First Name:
GWEN
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1295967776
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5800 N COURTENAY PKWY
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
MERRITT ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32953-7241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-615-1451
Provider Business Mailing Address Fax Number:
888-341-8272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3270 SUNTREE BLVD STE 207
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32940-7505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-615-0990
Provider Business Practice Location Address Fax Number:
888-341-8272
Provider Enumeration Date:
08/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW 10736 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 005043300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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