Provider Demographics
NPI:1013554435
Name:BRUSTAD, SAMANTHA (PSYD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BRUSTAD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9887 4TH ST N STE 319
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-8445
Mailing Address - Country:US
Mailing Address - Phone:727-379-2807
Mailing Address - Fax:
Practice Address - Street 1:9887 4TH ST N STE 319
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-8445
Practice Address - Country:US
Practice Address - Phone:727-379-2807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
FLPY10363103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health