Provider Demographics
NPI:1013560622
Name:BRUNNER, REBECCA ANNE (BCBA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE
Last Name:BRUNNER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 23RD ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-6310
Mailing Address - Country:US
Mailing Address - Phone:757-450-0383
Mailing Address - Fax:
Practice Address - Street 1:293 INDEPENDENCE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5461
Practice Address - Country:US
Practice Address - Phone:757-490-3009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-19-93360106S00000X
VA0133001875103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1396351193OtherABA