Provider Demographics
NPI:1447800024
Name:BUMGARNER, BROCK ANTHONY (QMHP)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:ANTHONY
Last Name:BUMGARNER
Suffix:
Gender:M
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 SW G ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2544
Mailing Address - Country:US
Mailing Address - Phone:541-476-2373
Mailing Address - Fax:
Practice Address - Street 1:1181 SW RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5835
Practice Address - Country:US
Practice Address - Phone:541-476-2373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health