Provider Demographics
NPI:1619193513
Name:BRUNO, ANDREA MARYANN (LMHC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARYANN
Last Name:BRUNO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 W HWY 50
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-2982
Mailing Address - Country:US
Mailing Address - Phone:352-394-5922
Mailing Address - Fax:
Practice Address - Street 1:655 W HWY 50
Practice Address - Street 2:SUITE 104 LIFESTREAM
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2982
Practice Address - Country:US
Practice Address - Phone:352-394-5922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2012-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11315101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL810268601Medicaid