MEDICARE: NICHOLAS DEAN BRUNNER LCAT

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	101200000X	Drama Therapist	002096	NY

General Provider Information

NPI Number	:	1508249434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS DEAN BRUNNER LCAT

Provider Business Mailing Address
First Line	:	4502 DITMARS BLVD STE 1032
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11105-1363
Country	:	US
Telephone Number	:	718-777-6398
Fax Number	:

Provider Business Practice Location Address
First Line	:	4502 DITMARS BLVD STE 1032
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11105-1363
Country	:	US
Telephone Number	:	718-777-6398
Fax Number	:

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

Provider Enumeration Date	:	07/09/2015
Last Update Date	:	06/21/2022

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Directions to “ NICHOLAS DEAN BRUNNER LCAT” Practice Location

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