Provider Demographics
NPI:1306662499
Name:MUNDY, TAMMY (LMT, CMLDT)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:MUNDY
Suffix:
Gender:F
Credentials:LMT, CMLDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1667 WILLOW DALE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-3512
Mailing Address - Country:US
Mailing Address - Phone:434-409-3817
Mailing Address - Fax:
Practice Address - Street 1:404 8TH ST NE STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-4755
Practice Address - Country:US
Practice Address - Phone:434-409-3817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-23
Last Update Date:2024-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019008685225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist