Provider Demographics
NPI:1689716862
Name:BRUNDAGE, VICTORIA (LCSW)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:BRUNDAGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 N 124TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4675
Mailing Address - Country:US
Mailing Address - Phone:262-641-4347
Mailing Address - Fax:262-641-4350
Practice Address - Street 1:2515 N 124TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4675
Practice Address - Country:US
Practice Address - Phone:262-641-4347
Practice Address - Fax:262-641-4350
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7313-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical