1396093340 NPI number — DR. BENEDETTO GIUSEPPE FORREST BRUNETTO PSY.D.

Table of content: DR. BENEDETTO GIUSEPPE FORREST BRUNETTO PSY.D. (NPI 1396093340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396093340 NPI number — DR. BENEDETTO GIUSEPPE FORREST BRUNETTO PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUNETTO
Provider First Name:
BENEDETTO
Provider Middle Name:
GIUSEPPE FORREST
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRUNETTO
Provider Other First Name:
BEN
Provider Other Middle Name:
GIUSEPPE FORREST
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSY.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1396093340
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1664 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL CAJON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92021-5201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-579-8685
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
451 RIVERVIEW PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTEE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92071-5829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-258-3089
Provider Business Practice Location Address Fax Number:
619-258-3203
Provider Enumeration Date:
08/23/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY30812 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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