Provider Demographics
NPI:1053061259
Name:BUNCH, BLAINE
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:
Last Name:BUNCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 BUCKATUNNA CHICORA CLARA RD
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:MS
Mailing Address - Zip Code:39367-7381
Mailing Address - Country:US
Mailing Address - Phone:601-381-1719
Mailing Address - Fax:
Practice Address - Street 1:1304 WALNUT ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2232
Practice Address - Country:US
Practice Address - Phone:601-735-9025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2524225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist