Provider Demographics
NPI:1508249434
Name:BRUNNER, NICHOLAS DEAN (LCAT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:DEAN
Last Name:BRUNNER
Suffix:
Gender:M
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 DITMARS BLVD STE 1032
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1363
Mailing Address - Country:US
Mailing Address - Phone:718-777-6398
Mailing Address - Fax:
Practice Address - Street 1:4502 DITMARS BLVD STE 1032
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-1363
Practice Address - Country:US
Practice Address - Phone:718-777-6398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002096101200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101200000XBehavioral Health & Social Service ProvidersDrama Therapist