=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063715035
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICIA ELLEN BUNK M.A.,LPC,NCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2010
-----------------------------------------------------
Last Update Date | 05/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1153 W HIGH ST STE 2
-----------------------------------------------------
City | EBENSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15931-1725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-341-8905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1153 W HIGH ST STE 2
-----------------------------------------------------
City | EBENSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15931-1725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-341-8905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PC006712
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------