Provider Demographics
NPI:1962656660
Name:BRUNELLE, DIANE RUTH (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:RUTH
Last Name:BRUNELLE
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 1:3437 CARMAN RD
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12303-5424
Mailing Address - Country:US
Mailing Address - Phone:518-357-0095
Mailing Address - Fax:518-357-4420
Practice Address - Street 1:3437 CARMAN RD
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12303-5424
Practice Address - Country:US
Practice Address - Phone:518-357-0095
Practice Address - Fax:518-357-4420
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071946-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker