Doctor Name: | MARY BRUNHAVER |
NPI Number: | 1730582396 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | LCPC |
License Number: | 180.009770 |
Business Practice Address: | 1161 Fortune Blvd Shiloh, IL - 622697385 |
Business Phone Number: | 6187959880 |
Business Fax Number: | |
Mailing Address: | 508 Talbert Pl, O FALLON |
State: | IL |
Postal Code: | 622694250 |
Phone Number: | 6187959880 |
Fax Number: | |
NPI Enumeration Date: | 09/26/2014 |
NPI Last Update Date: | 08/03/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | 180.009770 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IL |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |