=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326438698
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REX BUNNELL MLADC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2015
-----------------------------------------------------
Last Update Date | 01/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 379 PLEASANT VALLEY RD
-----------------------------------------------------
City | WOLFEBORO
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03894-4437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-387-9693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 645
-----------------------------------------------------
City | WOLFEBORO FALLS
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03896-0645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-387-9693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 0873
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------