Provider Demographics
NPI:1154306421
Name:BRUNKER, DOUGLAS BOWEN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:BOWEN
Last Name:BRUNKER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 W BROADWAY APT 1008
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-3210
Mailing Address - Country:US
Mailing Address - Phone:801-581-0194
Mailing Address - Fax:801-581-0193
Practice Address - Street 1:780 GUARDSMAN WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1374
Practice Address - Country:US
Practice Address - Phone:801-581-0194
Practice Address - Fax:801-581-0193
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14016335011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT261871OtherDESERET MUTUAL
UT942938348BR1OtherEDUCATORS MUTUAL
UT107032396101OtherINTRMTN. HEALTH CARE