Provider Demographics
NPI:1235676420
Name:BRUSTUEN, BETH A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:A
Last Name:BRUSTUEN
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 1:1050 JABARA AVE
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR JOHNSON A F B
Mailing Address - State:NC
Mailing Address - Zip Code:27531-2310
Mailing Address - Country:US
Mailing Address - Phone:919-722-1883
Mailing Address - Fax:
Practice Address - Street 1:1050 JABARA AVE
Practice Address - Street 2:
Practice Address - City:SEYMOUR JOHNSON A F B
Practice Address - State:NC
Practice Address - Zip Code:27531-2310
Practice Address - Country:US
Practice Address - Phone:919-722-1883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005609103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical