Provider Demographics
NPI:1770839805
Name:BUNGART, BARBARA PEARL (MA LPC)
Entity Type:Individual
Prefix:MRS
First Name:BARBARA
Middle Name:PEARL
Last Name:BUNGART
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 EAST MAIN STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:CENTREVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49032
Mailing Address - Country:US
Mailing Address - Phone:269-467-1000
Mailing Address - Fax:269-467-3075
Practice Address - Street 1:677 EAST MAIN STREET
Practice Address - Street 2:SUITE A
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032
Practice Address - Country:US
Practice Address - Phone:269-467-1000
Practice Address - Fax:269-467-3075
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013105101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1708146Medicaid