Healthcare Provider Details

I. General information

NPI: 1508249434
Provider Name (Legal Business Name): NICHOLAS DEAN BRUNNER LCAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 DITMARS BLVD STE 1032
ASTORIA NY
11105-1363
US

IV. Provider business mailing address

4502 DITMARS BLVD STE 1032
ASTORIA NY
11105-1363
US

V. Phone/Fax

Practice location:
  • Phone: 718-777-6398
  • Fax:
Mailing address:
  • Phone: 718-777-6398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number002096
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: