Provider Demographics
NPI:1457619157
Name:DEANGELIS BRUNNER, ELIANA M (LPAT)
Entity Type:Individual
Prefix:
First Name:ELIANA
Middle Name:M
Last Name:DEANGELIS BRUNNER
Suffix:
Gender:F
Credentials:LPAT
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:
Other - Last Name:BRUNNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LPAT, T-CADC
Mailing Address - Street 1:2306 WOODBOURNE AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1754
Mailing Address - Country:US
Mailing Address - Phone:502-523-7565
Mailing Address - Fax:
Practice Address - Street 1:3630 DUTCHMANS LN FL 2
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3216
Practice Address - Country:US
Practice Address - Phone:502-523-7565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0126101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY-0126Medicaid