Provider Demographics
NPI:1669891693
Name:BRUNDAGE, JOHN ALEXANDER
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ALEXANDER
Last Name:BRUNDAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2903 S 3RD ST
Mailing Address - Street 2:APT 1
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40208-1414
Mailing Address - Country:US
Mailing Address - Phone:937-414-3652
Mailing Address - Fax:
Practice Address - Street 1:1311 N DIXIE HWY
Practice Address - Street 2:BUILDING C
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2621
Practice Address - Country:US
Practice Address - Phone:270-769-1304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor