Provider Demographics
NPI:1154415636
Name:BRUNELL, COLETTE A (LCSW-C)
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:A
Last Name:BRUNELL
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6119 MINUTE HAND COURT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044
Mailing Address - Country:US
Mailing Address - Phone:410-730-3896
Mailing Address - Fax:
Practice Address - Street 1:5550 STERRETT PLCE
Practice Address - Street 2:SUITE 314
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044
Practice Address - Country:US
Practice Address - Phone:410-730-6119
Practice Address - Fax:410-290-6550
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD059941041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD36140003OtherCAREFIRST DC PLAN
MD30171OtherMAMSI ID
MD521885475OtherFED TAX ID
MD42560901OtherCAREFIRST MD PLAN