Provider Demographics
NPI:1821388711
Name:BRUNSON, SELENA LORRAINE
Entity Type:Individual
Prefix:MISS
First Name:SELENA
Middle Name:LORRAINE
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7059 SAN MIGUEL AVE
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-2102
Mailing Address - Country:US
Mailing Address - Phone:619-589-8296
Mailing Address - Fax:619-461-4518
Practice Address - Street 1:7059 SAN MIGUEL AVE
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-2102
Practice Address - Country:US
Practice Address - Phone:619-589-8296
Practice Address - Fax:619-461-4518
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health