Healthcare Provider Details

I. General information

NPI: 1780198770
Provider Name (Legal Business Name): LEON EDWARD BRUNTY CADCII
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2607 LEDO RD
ALBANY GA
31707-1211
US

IV. Provider business mailing address

179 BRUNTY RD
TY TY GA
31795-3601
US

V. Phone/Fax

Practice location:
  • Phone: 229-903-0022
  • Fax: 229-903-0025
Mailing address:
  • Phone: 218-393-9723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number770
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: