Provider Demographics
NPI:1194364992
Name:SUNDE, KESHTISHA
Entity Type:Individual
Prefix:
First Name:KESHTISHA
Middle Name:
Last Name:SUNDE
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 1:1039 STONERIDGE DR STE 5
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-7056
Mailing Address - Country:US
Mailing Address - Phone:406-624-6599
Mailing Address - Fax:
Practice Address - Street 1:1039 STONERIDGE DR STE 5
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-7056
Practice Address - Country:US
Practice Address - Phone:406-624-6599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-27
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT18-65321106S00000X
MTPSY-BA-LIC-3188103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician