Provider Demographics
NPI:1700517976
Name:BRUNSON, MIKISHA B
Entity Type:Individual
Prefix:
First Name:MIKISHA
Middle Name:B
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3659 W 128TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-4524
Mailing Address - Country:US
Mailing Address - Phone:440-670-6773
Mailing Address - Fax:
Practice Address - Street 1:1507 SAINT CLAIR AVE NE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-2003
Practice Address - Country:US
Practice Address - Phone:216-417-0047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator