Provider Demographics
NPI:1871646497
Name:BUKENBERGER, JOHN KENNETH (MFT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KENNETH
Last Name:BUKENBERGER
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7979
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-7979
Mailing Address - Country:US
Mailing Address - Phone:760-935-4957
Mailing Address - Fax:
Practice Address - Street 1:52 N TU SU LN
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-8058
Practice Address - Country:US
Practice Address - Phone:760-873-6394
Practice Address - Fax:760-873-3254
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC24829101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659433191OtherORGANIZATION NPI NUMBER