Provider Demographics
NPI:1154605426
Name:BRUNER, ALICIA D
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:D
Last Name:BRUNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12512 BANNOCKBURN PL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-4515
Mailing Address - Country:US
Mailing Address - Phone:405-414-4029
Mailing Address - Fax:
Practice Address - Street 1:12512 BANNOCKBURN PL
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-4515
Practice Address - Country:US
Practice Address - Phone:405-414-4029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YS0200X, 104100000X, 106H00000X
OK103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist