Provider Demographics
NPI:1356765721
Name:BRUSO, BENJAMIN MATTHEW (PCCI)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MATTHEW
Last Name:BRUSO
Suffix:
Gender:M
Credentials:PCCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1563 MISSION ST, SAN FRANCISCO, CA 94103
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103
Mailing Address - Country:US
Mailing Address - Phone:415-762-3700
Mailing Address - Fax:
Practice Address - Street 1:1563 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103
Practice Address - Country:US
Practice Address - Phone:415-762-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YS0200X
CA2401101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool