Provider Demographics
NPI:1457940959
Name:KUNSMAN, CAROL ROSE
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ROSE
Last Name:KUNSMAN
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 1:1611 W WYNVIEW LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8481
Mailing Address - Country:US
Mailing Address - Phone:610-216-0703
Mailing Address - Fax:
Practice Address - Street 1:164 E 5900 S STE 101
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7256
Practice Address - Country:US
Practice Address - Phone:801-261-5794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC011602101YP2500X
UT11011661-6010101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional