Provider Demographics
NPI:1043724776
Name:BRUNELLE, KARLEY MILLS (MA)
Entity type:Individual
Prefix:
First Name:KARLEY
Middle Name:MILLS
Last Name:BRUNELLE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3416 HEARTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-8572
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 SARNO RD STE 12
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4993
Practice Address - Country:US
Practice Address - Phone:321-622-4066
Practice Address - Fax:321-306-2879
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-16
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLIMH25292101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician