Provider Demographics
NPI:1407269707
Name:BRUNO, SALLYAN (BA)
Entity Type:Individual
Prefix:
First Name:SALLYAN
Middle Name:
Last Name:BRUNO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:874 W BROADWAY
Mailing Address - Street 2:C2
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2057
Mailing Address - Country:US
Mailing Address - Phone:201-456-3527
Mailing Address - Fax:
Practice Address - Street 1:874 W BROADWAY
Practice Address - Street 2:C2
Practice Address - City:WOODMERE
Practice Address - State:NY
Practice Address - Zip Code:11598-2057
Practice Address - Country:US
Practice Address - Phone:201-456-3527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ924736252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency