Healthcare Provider Details

I. General information

NPI: 1649004219
Provider Name (Legal Business Name): TREVOR BARTUNEK ACT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 08/27/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 HAINES AVE STE 6
RAPID CITY SD
57701-0710
US

IV. Provider business mailing address

1520 HAINES AVE STE 6
RAPID CITY SD
57701-0710
US

V. Phone/Fax

Practice location:
  • Phone: 605-716-7841
  • Fax: 605-718-0404
Mailing address:
  • Phone: 605-716-7841
  • Fax: 605-718-0404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number8627
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: