Healthcare Provider Details

I. General information

NPI: 1750354890
Provider Name (Legal Business Name): DONALD L MUNN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E BERRY ST
MIDDLEBURY IN
46540
US

IV. Provider business mailing address

PO BOX 63
MIDDLEBURY IN
46540
US

V. Phone/Fax

Practice location:
  • Phone: 574-825-7662
  • Fax: 574-825-3254
Mailing address:
  • Phone: 574-825-7662
  • Fax: 574-825-3254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34000437A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001177A
License Number StateIN

VIII. Authorized Official

Name: MR. DONALD L MUNN
Title or Position: OWNER
Credential: MSW ACSW LCSW LMFT
Phone: 574-825-7662