Provider Demographics
NPI:1053293357
Name:RUNDSTROM, MOLLIE A
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:A
Last Name:RUNDSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 FIR ST NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-4638
Mailing Address - Country:US
Mailing Address - Phone:316-558-0484
Mailing Address - Fax:
Practice Address - Street 1:4160 6TH AVE SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1039
Practice Address - Country:US
Practice Address - Phone:360-259-7179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-25
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC700028591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical