Provider Demographics
NPI:1922437649
Name:SUNBOM, GINGER
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:
Last Name:SUNBOM
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 1:4810 MCALLISTER ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-6362
Mailing Address - Country:US
Mailing Address - Phone:404-823-3709
Mailing Address - Fax:
Practice Address - Street 1:4810 MCALLISTER ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-6362
Practice Address - Country:US
Practice Address - Phone:404-823-3709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-01-0576103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst