Provider Demographics
NPI:1396092235
Name:BRUNELLE, SUSAN ELIZABETH (CBA, CBIS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:BRUNELLE
Suffix:
Gender:F
Credentials:CBA, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9854 MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80238-2993
Mailing Address - Country:US
Mailing Address - Phone:303-777-0702
Mailing Address - Fax:
Practice Address - Street 1:4851 INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6715
Practice Address - Country:US
Practice Address - Phone:303-425-0300
Practice Address - Fax:303-432-5071
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101Y00000X
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor