Healthcare Provider Details

I. General information

NPI: 1154605426
Provider Name (Legal Business Name): ALICIA D BRUNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12512 BANNOCKBURN PL
OKLAHOMA CITY OK
73142-4515
US

IV. Provider business mailing address

12512 BANNOCKBURN PL
OKLAHOMA CITY OK
73142-4515
US

V. Phone/Fax

Practice location:
  • Phone: 405-414-4029
  • Fax:
Mailing address:
  • Phone: 405-414-4029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: