Provider Demographics
NPI:1528039963
Name:BUNGE, KATHRYN M (LISW)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:M
Last Name:BUNGE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 S 8TH ST
Mailing Address - Street 2:SUITE #207
Mailing Address - City:CLEAR LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50428-2577
Mailing Address - Country:US
Mailing Address - Phone:641-357-0272
Mailing Address - Fax:641-357-3059
Practice Address - Street 1:518 S 8TH ST
Practice Address - Street 2:SUITE #207
Practice Address - City:CLEAR LAKE
Practice Address - State:IA
Practice Address - Zip Code:50428-2577
Practice Address - Country:US
Practice Address - Phone:641-357-0272
Practice Address - Fax:641-357-3059
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA21957OtherMIDLANDS
IA04645OtherWELLMARK BLUE SHIELD
IA04645OtherWELLMARK ALLIANCE SELECT
IAI10854Medicare ID - Type UnspecifiedMEDICARE PART B