Provider Demographics
NPI:1124664602
Name:BRUNKOWSKI, CAROL ANN (SCHOOL PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:ANN
Last Name:BRUNKOWSKI
Suffix:
Gender:F
Credentials:SCHOOL PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 W GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4104
Mailing Address - Country:US
Mailing Address - Phone:773-883-3071
Mailing Address - Fax:
Practice Address - Street 1:4930 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-2616
Practice Address - Country:US
Practice Address - Phone:773-285-8040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1989567103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty