Provider Demographics
NPI:1457865164
Name:BUNTEN, KEVIN S (MSED, MDIV, LCPC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:S
Last Name:BUNTEN
Suffix:
Gender:M
Credentials:MSED, MDIV, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 WALL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1959
Mailing Address - Country:US
Mailing Address - Phone:618-367-2194
Mailing Address - Fax:618-726-2024
Practice Address - Street 1:785 WALL ST STE 200
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1959
Practice Address - Country:US
Practice Address - Phone:618-367-2194
Practice Address - Fax:618-726-2024
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.011138101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGOtherPENDING