Provider Demographics
NPI:1174809511
Name:ELIZABETH G BRUNING PHD PLLC
Entity type:Organization
Organization Name:ELIZABETH G BRUNING PHD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:G
Authorized Official - Last Name:BRUNING
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:231-935-0790
Mailing Address - Street 1:818 RED DRIVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684
Mailing Address - Country:US
Mailing Address - Phone:231-935-0790
Mailing Address - Fax:231-935-0791
Practice Address - Street 1:818 RED DR
Practice Address - Street 2:SUITE 260
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4720
Practice Address - Country:US
Practice Address - Phone:231-935-0790
Practice Address - Fax:231-935-0791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008608103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM21750OtherMEDICARE PTAN
MIOM21750OtherMEDICARE PTAN