Basic Information
| Provider Information | |||||||||
| NPI: | 1770557274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUNKLE | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | GREENE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.P.E. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 DONS WAY | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016205130 | ||||||||
| FaxNumber: | 5016205203 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 W GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719013931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016247111 | ||||||||
| FaxNumber: | 5016205109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 12/17/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 79-6E | AR | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 116399726 | 05 | AR | MEDICAID | 5T141 | 01 | AR | BLUE CROSS & BLUE SHIELD | OTHER |