Provider Demographics
NPI:1760592380
Name:MARY A BRUGGEMAN, PH.D.
Entity Type:Organization
Organization Name:MARY A BRUGGEMAN, PH.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BRUGGEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:805-481-8766
Mailing Address - Street 1:912 DODSON WAY
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420
Mailing Address - Country:US
Mailing Address - Phone:805-481-8766
Mailing Address - Fax:805-481-8756
Practice Address - Street 1:912 DODSON WAY
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420
Practice Address - Country:US
Practice Address - Phone:805-481-8766
Practice Address - Fax:805-481-8756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP10051Medicare UPIN
CACP10051Medicare ID - Type Unspecified