Provider Demographics
NPI:1568823300
Name:AMY AND BRANDON PUNG, LLC
Entity Type:Organization
Organization Name:AMY AND BRANDON PUNG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:PUNG
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:269-993-7672
Mailing Address - Street 1:4356 SQUIRE HEATH RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4060
Mailing Address - Country:US
Mailing Address - Phone:269-993-7672
Mailing Address - Fax:
Practice Address - Street 1:2031 RAMBLING RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1632
Practice Address - Country:US
Practice Address - Phone:269-993-7670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010846591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty