Healthcare Provider Details

I. General information

NPI: 1891212767
Provider Name (Legal Business Name): GEORGE BRANDON MUNCY MS, ED.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N JORDAN AVE
BLOOMINGTON IN
47405-3190
US

IV. Provider business mailing address

600 N JORDAN AVE
BLOOMINGTON IN
47405-3190
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-5711
  • Fax:
Mailing address:
  • Phone: 812-855-5711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1142
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: