Provider Demographics
NPI:1780072835
Name:BRUNS, PAUL EDWARD (LCAC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:EDWARD
Last Name:BRUNS
Suffix:
Gender:M
Credentials:LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 IMPERIAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-4233
Mailing Address - Country:US
Mailing Address - Phone:260-636-6884
Mailing Address - Fax:260-636-3392
Practice Address - Street 1:101 E PARK DR
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:IN
Practice Address - Zip Code:46701-1438
Practice Address - Country:US
Practice Address - Phone:260-636-6884
Practice Address - Fax:260-636-3392
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001558A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)