Provider Demographics
NPI:1508387317
Name:BRUNER, JOHN PATRICK (MA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PATRICK
Last Name:BRUNER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3122 PALMER DR APT 3
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1386
Mailing Address - Country:US
Mailing Address - Phone:225-287-4484
Mailing Address - Fax:
Practice Address - Street 1:8311 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2529
Practice Address - Country:US
Practice Address - Phone:708-771-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health