Provider Demographics
NPI:1891414504
Name:MUNDY, PRUDENCE
Entity type:Individual
Prefix:
First Name:PRUDENCE
Middle Name:
Last Name:MUNDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 MARTIN DR
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-1615
Mailing Address - Country:US
Mailing Address - Phone:937-562-2400
Mailing Address - Fax:
Practice Address - Street 1:452 W MARKET ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2815
Practice Address - Country:US
Practice Address - Phone:937-376-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCII.162039101YA0400X
225400000X
OHW.2300390104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner