Provider Demographics
NPI:1043679194
Name:BUNDRUM, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BUNDRUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:GIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:517 DELTONA BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-8016
Mailing Address - Country:US
Mailing Address - Phone:407-770-9291
Mailing Address - Fax:
Practice Address - Street 1:1450 S KENANSVILLE RD
Practice Address - Street 2:
Practice Address - City:KENANSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34739-9637
Practice Address - Country:US
Practice Address - Phone:407-770-9291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW157491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical