Provider Demographics
NPI:1861578098
Name:BRUNNER, KURT MICHAEL (MSSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:KURT
Middle Name:MICHAEL
Last Name:BRUNNER
Suffix:
Gender:M
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S HUNTINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4817
Mailing Address - Country:US
Mailing Address - Phone:617-390-4790
Mailing Address - Fax:857-364-6868
Practice Address - Street 1:150 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-4817
Practice Address - Country:US
Practice Address - Phone:617-390-4790
Practice Address - Fax:857-364-6868
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1268081211041C0700X
WI7433-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1861578098Medicaid