Provider Demographics
NPI:1235703828
Name:BRUTON, LAURA SUANN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:SUANN
Last Name:BRUTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 NW CROSSROADS APT 2023
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-2179
Mailing Address - Country:US
Mailing Address - Phone:830-370-2792
Mailing Address - Fax:
Practice Address - Street 1:835 PROTON RD # 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4203
Practice Address - Country:US
Practice Address - Phone:210-610-9175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician