MEDICARE: HERSCHEL L. BRUNNER PSY.D.

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	103T00000X	Psychologist	882	LA
2	103TM1800X	Intellectual & Developmental Disabilities Psychologist	882	LA
3	103TB0200X	Cognitive & Behavioral Psychologist	882	LA

General Provider Information

NPI Number	:	1326274143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HERSCHEL L. BRUNNER PSY.D.

Provider Business Mailing Address
First Line	:	620 N MORRISON BLVD STE G
Second Line	:
City	:	HAMMOND
State	:	LA
Zip	:	70401-2312
Country	:	US
Telephone Number	:	985-543-4113
Fax Number	:

Provider Business Practice Location Address
First Line	:	620 N MORRISON BLVD STE G
Second Line	:
City	:	HAMMOND
State	:	LA
Zip	:	70401-2312
Country	:	US
Telephone Number	:	985-543-4113
Fax Number	:

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

Provider Enumeration Date	:	06/08/2009
Last Update Date	:	12/06/2011

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