Provider Demographics
NPI:1124896915
Name:MUNDT, KEVIN T (PSYD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:T
Last Name:MUNDT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3219
Mailing Address - Country:US
Mailing Address - Phone:551-427-3290
Mailing Address - Fax:
Practice Address - Street 1:11 GARDEN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3219
Practice Address - Country:US
Practice Address - Phone:551-427-3290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ11746103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist