=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518695014
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEVIN M BRUNSTON LMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2022
-----------------------------------------------------
Last Update Date | 10/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 WAMPANOAG TRAIL SUITE 400
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-355-3881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 CUTLER STREET 1
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02885-1982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-563-1023
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MHC01688
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------