1174809511 NPI number — ELIZABETH G BRUNING PHD PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174809511 NPI number — ELIZABETH G BRUNING PHD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELIZABETH G BRUNING PHD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174809511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
818 RED DRIVE
Provider Second Line Business Mailing Address:
SUITE 260
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49684
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-935-0790
Provider Business Mailing Address Fax Number:
231-935-0791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
818 RED DR
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49684-4720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-935-0790
Provider Business Practice Location Address Fax Number:
231-935-0791
Provider Enumeration Date:
10/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BRUNING
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
231-935-0790

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  6301008608 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: OM21750 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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