Healthcare Provider Details

I. General information

NPI: 1679350151
Provider Name (Legal Business Name): GLEN ANTHONY BRUNO JR. MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/11/2023
Certification Date: 09/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 RAMONA EXPY
PERRIS CA
92571-7014
US

IV. Provider business mailing address

36217 PURSH DR
LAKE ELSINORE CA
92532-2518
US

V. Phone/Fax

Practice location:
  • Phone: 951-349-4195
  • Fax:
Mailing address:
  • Phone: 310-435-0090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number103466
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: