Provider Demographics
NPI:1538031497
Name:BRULLA, MIRANDA LEIGH (MS)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEIGH
Last Name:BRULLA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 W 36TH ST # 205
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2415
Mailing Address - Country:US
Mailing Address - Phone:570-604-2460
Mailing Address - Fax:
Practice Address - Street 1:1014 W 36TH ST # 205
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2415
Practice Address - Country:US
Practice Address - Phone:570-604-2460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-20
Last Update Date:2025-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA01075101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty