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General NPI Number Information
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NPI Number | 1295967776
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Entity Type | Individual
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Provider Name | GWEN MUNDORF MSW, LCSW
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Gender | Female
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Dates
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Enumeration Date | 08/17/2009
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Last Update Date | 03/19/2025
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Provider Practice Location Address
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Address Line | 3270 SUNTREE BLVD STE 207
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City | MELBOURNE
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State | FL
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Zip | 32940-7505
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Country | US
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Telephone | 321-615-0990
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Fax | 888-341-8272
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Provider Business Mailing Address
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Address Line | 5800 N COURTENAY PKWY SUITE C
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City | MERRITT ISLAND
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State | FL
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Zip | 32953-7241
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Country | US
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Telephone | 321-615-1451
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Fax | 888-341-8272
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW 10736
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License Number State | FL
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