MEDICARE: REX BUNNELL MLADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	0873	NH

General Provider Information

NPI Number	:	1326438698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REX BUNNELL MLADC

Provider Business Mailing Address
First Line	:	PO BOX 645
Second Line	:
City	:	WOLFEBORO FALLS
State	:	NH
Zip	:	03896-0645
Country	:	US
Telephone Number	:	603-387-9693
Fax Number	:

Provider Business Practice Location Address
First Line	:	379 PLEASANT VALLEY RD
Second Line	:
City	:	WOLFEBORO
State	:	NH
Zip	:	03894-4437
Country	:	US
Telephone Number	:	603-387-9693
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2015
Last Update Date	:	01/26/2015

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