Provider Demographics
NPI:1366919730
Name:BRUNSON, GINA MARIE (RBT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 FERGUSON DR APT 203
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-7153
Mailing Address - Country:US
Mailing Address - Phone:404-754-9663
Mailing Address - Fax:
Practice Address - Street 1:538 APRICOT ST
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-2555
Practice Address - Country:US
Practice Address - Phone:540-623-4127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty