Provider Demographics
NPI:1144787995
Name:BRUNSON, CORBIN DANIEL
Entity Type:Individual
Prefix:
First Name:CORBIN
Middle Name:DANIEL
Last Name:BRUNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6479 CAROLINE ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-4502
Mailing Address - Country:US
Mailing Address - Phone:850-910-4089
Mailing Address - Fax:
Practice Address - Street 1:6479 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-4502
Practice Address - Country:US
Practice Address - Phone:850-910-4089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-187669106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician