Provider Demographics
NPI:1356585715
Name:MUNDT, TANJA NICOLE (MA, LPC-S)
Entity type:Individual
Prefix:MS
First Name:TANJA
Middle Name:NICOLE
Last Name:MUNDT
Suffix:
Gender:F
Credentials:MA, LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4765 S LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7197
Mailing Address - Country:US
Mailing Address - Phone:913-904-8565
Mailing Address - Fax:
Practice Address - Street 1:4765 S LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7197
Practice Address - Country:US
Practice Address - Phone:913-904-8565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007008419101YP2500X
AZ17307101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional