Provider Demographics
NPI:1770032906
Name:KUNNEMANN, KANDRA L (MS, LPC)
Entity Type:Individual
Prefix:
First Name:KANDRA
Middle Name:L
Last Name:KUNNEMANN
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W WALNUT ST APT A204
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-8201
Mailing Address - Country:US
Mailing Address - Phone:573-528-8370
Mailing Address - Fax:
Practice Address - Street 1:1200 W WALNUT ST APT A204
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-8201
Practice Address - Country:US
Practice Address - Phone:573-528-8370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016036618101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490040853Medicaid
MO13975808OtherCAQH