Provider Demographics
NPI:1114564960
Name:BUNNELL, ANDREW WARREN
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:WARREN
Last Name:BUNNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 CHALLENGER WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5418
Mailing Address - Country:US
Mailing Address - Phone:707-565-4943
Mailing Address - Fax:
Practice Address - Street 1:2245 CHALLENGER WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5418
Practice Address - Country:US
Practice Address - Phone:707-565-4943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA183681041C0700X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical