Provider Demographics
NPI:1659975159
Name:BUNYAK, KELSEY L (MED)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:L
Last Name:BUNYAK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46200 PORT ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-6048
Mailing Address - Country:US
Mailing Address - Phone:734-454-0866
Mailing Address - Fax:734-454-1744
Practice Address - Street 1:46200 PORT ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6048
Practice Address - Country:US
Practice Address - Phone:734-454-0866
Practice Address - Fax:734-454-1744
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401001286103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst