Provider Demographics
NPI:1871284711
Name:BRUNK, ANDIE JO (LMFT)
Entity type:Individual
Prefix:
First Name:ANDIE
Middle Name:JO
Last Name:BRUNK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5479 CAMINO COMPADRE
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8624
Mailing Address - Country:US
Mailing Address - Phone:805-340-5470
Mailing Address - Fax:
Practice Address - Street 1:1722 S LEWIS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8520
Practice Address - Country:US
Practice Address - Phone:805-366-4205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13476101YP2500X
CA152566106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional