Provider Demographics
NPI:1043955271
Name:BRUBAKER, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:NIEVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, FL REG INTERN
Mailing Address - Street 1:3256 W LAKE MARY BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3588
Mailing Address - Country:US
Mailing Address - Phone:407-429-9030
Mailing Address - Fax:
Practice Address - Street 1:3256 W LAKE MARY BLVD
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3588
Practice Address - Country:US
Practice Address - Phone:407-429-9030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH21660101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health