Provider Demographics
NPI:1134454457
Name:BRUNT, CLARISSA L (MA)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:L
Last Name:BRUNT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 W IMPERIAL HWY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-3835
Mailing Address - Country:US
Mailing Address - Phone:800-998-6329
Mailing Address - Fax:714-784-2945
Practice Address - Street 1:915 W IMPERIAL HWY
Practice Address - Street 2:SUITE 150
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3835
Practice Address - Country:US
Practice Address - Phone:800-998-6329
Practice Address - Fax:714-784-2945
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF56562106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist