Provider Demographics
NPI:1720856784
Name:BRUNGOT, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:BRUNGOT
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 1:118 HAZELWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TOANO
Mailing Address - State:VA
Mailing Address - Zip Code:23168-9320
Mailing Address - Country:US
Mailing Address - Phone:757-634-2215
Mailing Address - Fax:
Practice Address - Street 1:501 VILLAGE AVE STE 204
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23693-5657
Practice Address - Country:US
Practice Address - Phone:757-568-5904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016218101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health