Provider Demographics
NPI:1578873584
Name:CHOLULA BRUNO, JOSE ANTONIO (MA, EDD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
Last Name:CHOLULA BRUNO
Suffix:
Gender:M
Credentials:MA, EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 CABRILLO PARK DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-5017
Mailing Address - Country:US
Mailing Address - Phone:714-953-4455
Mailing Address - Fax:714-547-8856
Practice Address - Street 1:525 CABRILLO PARK DR
Practice Address - Street 2:SUITE 300
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5017
Practice Address - Country:US
Practice Address - Phone:714-953-4455
Practice Address - Fax:714-547-8856
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPSY32179103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical