Healthcare Provider Details

I. General information

NPI: 1548929367
Provider Name (Legal Business Name): KEN BUMKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 CEDAR ST
MISSOULA MT
59802-3911
US

IV. Provider business mailing address

2186 AMITY LN
MISSOULA MT
59804-5107
US

V. Phone/Fax

Practice location:
  • Phone: 406-541-4673
  • Fax:
Mailing address:
  • Phone: 406-239-5380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-SWLC-LIC-49297
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: