Provider Demographics
NPI:1215676713
Name:MUNDY, ERICA
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:MUNDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:VAN SOELEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:4211 PARKWAY PLACE DR SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2695
Practice Address - Country:US
Practice Address - Phone:616-222-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MI6451023235101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health