1710956800 NPI number — MR. PAUL RONALD MUNDT LMFT

Table of content: MR. PAUL RONALD MUNDT LMFT (NPI 1710956800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710956800 NPI number — MR. PAUL RONALD MUNDT LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUNDT
Provider First Name:
PAUL
Provider Middle Name:
RONALD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710956800
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17291 IRVINE BLVD.
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
TUSTIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-270-0200
Provider Business Mailing Address Fax Number:
807-566-3041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17291 IRVINE BLVD.
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-270-0200
Provider Business Practice Location Address Fax Number:
807-566-3041
Provider Enumeration Date:
03/14/2006

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: 106H00000X , with the licence number:  49936 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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