Healthcare Provider Details

I. General information

NPI: 1659093706
Provider Name (Legal Business Name): ELIZABETH BUMANGLAG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W MARKET ST
COLUMBIA CITY IN
46725-2311
US

IV. Provider business mailing address

2621 E JEFFERSON ST
WARSAW IN
46580-3880
US

V. Phone/Fax

Practice location:
  • Phone: 260-248-8176
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: