Provider Demographics
NPI:1932389251
Name:BRUNSON, CORNELL J (MS, LCADC)
Entity Type:Individual
Prefix:MR
First Name:CORNELL
Middle Name:J
Last Name:BRUNSON
Suffix:
Gender:M
Credentials:MS, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1066 NEW PEAR ST
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-3940
Mailing Address - Country:US
Mailing Address - Phone:856-776-6649
Mailing Address - Fax:856-696-4799
Practice Address - Street 1:2630 E CHESTNUT AVE
Practice Address - Street 2:SUITE D-4
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08361-8400
Practice Address - Country:US
Practice Address - Phone:856-776-6649
Practice Address - Fax:856-696-4799
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00095400101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ11767849OtherAETNA