Provider Demographics
NPI:1962403337
Name:BRUNGARD, ROBIN CAROL (LCSW-C)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:CAROL
Last Name:BRUNGARD
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:CAROL
Other - Last Name:LINTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:PO BOX 1631
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-1631
Mailing Address - Country:US
Mailing Address - Phone:443-968-9266
Mailing Address - Fax:410-414-5911
Practice Address - Street 1:489 MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3187
Practice Address - Country:US
Practice Address - Phone:443-968-9266
Practice Address - Fax:410-414-5911
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD112181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
278928-000OtherMAGELLAN
10763028OtherCAQH
MD604857-02OtherCAREFIRST BC/BS
MD402796500Medicaid
F453-0002OtherCAREFIRST BLUECHOICE