Healthcare Provider Details

I. General information

NPI: 1205047669
Provider Name (Legal Business Name): BRIAN JERMOE VAN BRUNT EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 BRIDGE ST
HENNIKER NH
03242-3202
US

IV. Provider business mailing address

PO BOX 391
HENNIKER NH
03242-0391
US

V. Phone/Fax

Practice location:
  • Phone: 603-491-3215
  • Fax:
Mailing address:
  • Phone: 603-491-3215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number306
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: