Provider Demographics
NPI:1033137302
Name:BRUNDAGE, MICHAEL (LMFT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BRUNDAGE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 838
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92609-0838
Mailing Address - Country:US
Mailing Address - Phone:949-293-0382
Mailing Address - Fax:
Practice Address - Street 1:25283 CABOT RD
Practice Address - Street 2:SUITE 107
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5522
Practice Address - Country:US
Practice Address - Phone:949-293-0382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 44886106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist