Healthcare Provider Details

I. General information

NPI: 1417567173
Provider Name (Legal Business Name): AUSTINA BRUTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 WAVELAND AVE
WINCHESTER KY
40391-1231
US

IV. Provider business mailing address

1801 WATERMARK DR STE 200
COLUMBUS OH
43215-7088
US

V. Phone/Fax

Practice location:
  • Phone: 859-514-6028
  • Fax:
Mailing address:
  • Phone: 614-487-8758
  • Fax: 614-227-9447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number264034
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: