Provider Demographics
NPI:1053526376
Name:MUNDT, KAREN SUE (C-SAC)
Entity type:Individual
Prefix:MS
First Name:KAREN
Middle Name:SUE
Last Name:MUNDT
Suffix:
Gender:F
Credentials:C-SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1845
Mailing Address - Country:US
Mailing Address - Phone:715-305-8112
Mailing Address - Fax:
Practice Address - Street 1:132 W STATE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1735
Practice Address - Country:US
Practice Address - Phone:715-305-8112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11414-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11414-132OtherSTATE LICENSE NUMBERS
WI39385400Medicaid