1104936434 NPI number — DR. GREG MARTIN BRUNO PH.D AND LCSW

Table of content: DR. GREG MARTIN BRUNO PH.D AND LCSW (NPI 1104936434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104936434 NPI number — DR. GREG MARTIN BRUNO PH.D AND LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUNO
Provider First Name:
GREG
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D AND LCSW
Provider Gender Code:
M

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:
1104936434
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
740 FRONT ST
Provider Second Line Business Mailing Address:
SUITE 320
Provider Business Mailing Address City Name:
SANTA CRUZ
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95060-4535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-588-7299
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
740 FRONT ST
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
SANTA CRUZ
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95060-4535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-588-7299
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2006

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: 103T00000X , with the licence number:  PSY 14956 , 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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