MEDICARE: MS. KELLI ERIN BRUNK LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW0004255	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134119282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLI ERIN BRUNK LCSW

Provider Business Mailing Address
First Line	:	4000 NE 168 ST
Second Line	:	#6-B
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33160-3500
Country	:	US
Telephone Number	:	786-385-6754
Fax Number	:	305-944-6184

Provider Business Practice Location Address
First Line	:	1031 IVES DAIRY RD
Second Line	:	STE 228
City	:	MIAMI
State	:	FL
Zip	:	33179-2538
Country	:	US
Telephone Number	:	786-385-6754
Fax Number	:	305-944-6184

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	07/08/2007

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