Provider Demographics
NPI:1821240524
Name:BRUNSON, DOROTHY ANGELA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:ANGELA
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT #2130, PO BOX 11407
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-2130
Mailing Address - Country:US
Mailing Address - Phone:601-925-6805
Mailing Address - Fax:601-926-4971
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPT OF OTOLARYNGOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2429235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00981345Medicaid
MS00981345Medicaid