Provider Demographics
NPI:1265452346
Name:BRUNDAGE, JANET LORAINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JANET
Middle Name:LORAINE
Last Name:BRUNDAGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2020 COUNTY ROAD H
Mailing Address - Street 2:#526
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147
Mailing Address - Country:US
Mailing Address - Phone:262-227-0606
Mailing Address - Fax:
Practice Address - Street 1:2028 N SEMINARY AVENUE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098
Practice Address - Country:US
Practice Address - Phone:815-338-3590
Practice Address - Fax:815-227-4406
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1617-1231041C0700X
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL332-2740Medicare ID - Type Unspecified