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General NPI Number Information
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NPI Number | 1942369194
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Entity Type | Organization
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Legal Business Name | KENNETH A. BUNDZA AND SHERWIN Y. KEPES
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6026 E STATE BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46815-7639
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Country | US
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Telephone | 260-749-8419
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Fax | 260-749-0553
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Provider Business Mailing Address
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Address Line | 6026 E STATE BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46815-7639
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Country | US
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Telephone | 260-749-8419
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Fax | 260-749-0553
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Authorized Official
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Title or Position | PARTNER
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Name | DR. KENNETH A. BUNDZA
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Credential | PH.D.
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Telephone | 260-749-8419
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 20010117A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 20010242A
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License Number State | IN
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