MEDICARE: SUSAN ANNE BRUNELLI PH.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	103G00000X	Clinical Neuropsychologist	011050-1	NY

General Provider Information

NPI Number	:	1942576822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN ANNE BRUNELLI PH.D.

Provider Business Mailing Address
First Line	:	54 BOULEVARD
Second Line	:
City	:	SUFFERN
State	:	NY
Zip	:	10901-6120
Country	:	US
Telephone Number	:	845-598-4621
Fax Number	:

Provider Business Practice Location Address
First Line	:	341 77TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-3109
Country	:	US
Telephone Number	:	718-745-1856
Fax Number	:

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

Provider Enumeration Date	:	03/26/2012
Last Update Date	:	03/26/2012

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