Provider Demographics
NPI:1760629844
Name:BUNCH, PHYLLIS PAIGE
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:PAIGE
Last Name:BUNCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10737 LAUREL ST STE 230
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7659
Mailing Address - Country:US
Mailing Address - Phone:909-989-5556
Mailing Address - Fax:
Practice Address - Street 1:10737 LAUREL ST STE 230
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7659
Practice Address - Country:US
Practice Address - Phone:909-989-5556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC45102106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist