Provider Demographics
NPI:1871756171
Name:BUNDY, MARY E (LAC, OTR/L)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:BUNDY
Suffix:
Gender:F
Credentials:LAC, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4405
Mailing Address - Country:US
Mailing Address - Phone:772-263-3956
Mailing Address - Fax:
Practice Address - Street 1:318 S FRANCES ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3208
Practice Address - Country:US
Practice Address - Phone:772-263-3956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31001987A225X00000X
IN84000148A171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No171100000XOther Service ProvidersAcupuncturist