Provider Demographics
NPI:1548929367
Name:BUMKE, KEN
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:BUMKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2186 AMITY LN
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-5107
Mailing Address - Country:US
Mailing Address - Phone:406-239-5380
Mailing Address - Fax:
Practice Address - Street 1:1120 CEDAR ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-3911
Practice Address - Country:US
Practice Address - Phone:406-541-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-SWLC-LIC-492971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical