Provider Demographics
NPI:1780023150
Name:BRUNNER, PAMELA ZANE (PHD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ZANE
Last Name:BRUNNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 WIKIUP DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-7700
Mailing Address - Country:US
Mailing Address - Phone:707-484-0319
Mailing Address - Fax:
Practice Address - Street 1:124 WIKIUP DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7700
Practice Address - Country:US
Practice Address - Phone:707-484-0319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 25711103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist