Provider Demographics
NPI:1124226998
Name:BUNDY, MISSY JEAN (PSYD)
Entity type:Individual
Prefix:
First Name:MISSY
Middle Name:JEAN
Last Name:BUNDY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 N SEDGWICK ST
Mailing Address - Street 2:UNIT N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4766
Mailing Address - Country:US
Mailing Address - Phone:773-244-0373
Mailing Address - Fax:
Practice Address - Street 1:4909 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-3161
Practice Address - Country:US
Practice Address - Phone:773-921-7805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71006608103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist