MEDICARE: LARRY BRUNSON LLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1477208510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LARRY BRUNSON LLC

Provider Business Mailing Address
First Line	:	3135 ALBRIGHT CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-1301
Country	:	US
Telephone Number	:	317-985-3119
Fax Number	:

Provider Business Practice Location Address
First Line	:	3135 ALBRIGHT CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-1301
Country	:	US
Telephone Number	:	317-985-3119
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LARRY BRUNSON
Credential	:
Telephone Number	:	317-985-3119

Provider Enumeration Date	:	02/17/2022
Last Update Date	:	02/17/2022

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