Provider Demographics
NPI:1154094357
Name:BUNNELL, DOUGLAS B (LAC)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:B
Last Name:BUNNELL
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61262 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:ST IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865-9124
Mailing Address - Country:US
Mailing Address - Phone:406-381-3962
Mailing Address - Fax:
Practice Address - Street 1:61262 WATSON RD
Practice Address - Street 2:
Practice Address - City:ST IGNATIUS
Practice Address - State:MT
Practice Address - Zip Code:59865-9124
Practice Address - Country:US
Practice Address - Phone:406-381-3962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2024-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-70021101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)