MEDICARE: RICHARD MARLIN KUNKLE LCSW

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	1041C0700X	Clinical Social Worker	LCSW2818	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	734310	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1487610325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD MARLIN KUNKLE LCSW

Provider Business Mailing Address
First Line	:	2500 SHOW LOW LAKE RD
Second Line	:
City	:	SHOW LOW
State	:	AZ
Zip	:	85901-7929
Country	:	US
Telephone Number	:	928-537-2951
Fax Number	:	928-537-8520

Provider Business Practice Location Address
First Line	:	2500 SHOW LOW LAKE RD
Second Line	:
City	:	SHOW LOW
State	:	AZ
Zip	:	85901-7929
Country	:	US
Telephone Number	:	928-537-2951
Fax Number	:	928-537-8520

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

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	07/08/2007

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