Provider Demographics
NPI:1730582396
Name:BRUNHAVER, MARY (LCPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BRUNHAVER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 TALBERT PL
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-4250
Mailing Address - Country:US
Mailing Address - Phone:618-795-9880
Mailing Address - Fax:
Practice Address - Street 1:1161 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7385
Practice Address - Country:US
Practice Address - Phone:618-795-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009770101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health