=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922022573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOAN SUE BRUNER LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 07/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3344 4TH AVE STE 200
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-291-3931
-----------------------------------------------------
Fax | 619-299-7410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3636 1ST AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-4072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-291-3931
-----------------------------------------------------
Fax | 619-299-7410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCS13114
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------