Provider Demographics
NPI:1295378826
Name:BRUNKHORST, PEYTON REANNE I
Entity Type:Individual
Prefix:
First Name:PEYTON
Middle Name:REANNE
Last Name:BRUNKHORST
Suffix:I
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 1:204 NW END BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5308
Mailing Address - Country:US
Mailing Address - Phone:314-769-1106
Mailing Address - Fax:
Practice Address - Street 1:204 NW END BLVD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5308
Practice Address - Country:US
Practice Address - Phone:314-769-1106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-27
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Single Specialty