Provider Demographics
NPI:1881746790
Name:BUNKER, ANA JACOBA (LISW)
Entity type:Individual
Prefix:MS
First Name:ANA
Middle Name:JACOBA
Last Name:BUNKER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CALLE MEDICO STE 5
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4705
Mailing Address - Country:US
Mailing Address - Phone:505-983-1410
Mailing Address - Fax:
Practice Address - Street 1:11 CALLE MEDICO STE 5
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4705
Practice Address - Country:US
Practice Address - Phone:505-983-1410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-05509101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM87986868Medicaid