Provider Demographics
NPI:1982923249
Name:BRUNSON, DIANA M (LMT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 TURNINGLEAF LN
Mailing Address - Street 2:
Mailing Address - City:DALZELL
Mailing Address - State:SC
Mailing Address - Zip Code:29040
Mailing Address - Country:US
Mailing Address - Phone:803-499-6744
Mailing Address - Fax:
Practice Address - Street 1:712 BULTMAN DR
Practice Address - Street 2:STE A
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2553
Practice Address - Country:US
Practice Address - Phone:803-774-2639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMAS6459225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist