Healthcare Provider Details

I. General information

NPI: 1679163653
Provider Name (Legal Business Name): TRAVIS MICHAEL BRUNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N VANDEMARK RD
SIDNEY OH
45365-3567
US

IV. Provider business mailing address

1011 N VANDEMARK RD
SIDNEY OH
45365-3567
US

V. Phone/Fax

Practice location:
  • Phone: 937-622-7393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.2505090
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: