Provider Demographics
NPI:1477208510
Name:LARRY BRUNSON LLC
Entity Type:Organization
Organization Name:LARRY BRUNSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-985-3119
Mailing Address - Street 1:3135 ALBRIGHT CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-1301
Mailing Address - Country:US
Mailing Address - Phone:317-985-3119
Mailing Address - Fax:
Practice Address - Street 1:3135 ALBRIGHT CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1301
Practice Address - Country:US
Practice Address - Phone:317-985-3119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty