Provider Demographics
NPI:1518422088
Name:BRUNER, ALLISON JEANETTE (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:JEANETTE
Last Name:BRUNER
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-7244
Mailing Address - Country:US
Mailing Address - Phone:573-986-4985
Mailing Address - Fax:
Practice Address - Street 1:611 N FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-7244
Practice Address - Country:US
Practice Address - Phone:573-986-4985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018033386103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018033386Medicaid