Healthcare Provider Details

I. General information

NPI: 1619193513
Provider Name (Legal Business Name): ANDREA MARYANN BRUNO LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W HWY 50 SUITE 104 LIFESTREAM
CLERMONT FL
34711-2982
US

IV. Provider business mailing address

655 W HWY 50
CLERMONT FL
34711-2982
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-5922
  • Fax:
Mailing address:
  • Phone: 352-394-5922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11315
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: