Basic Information
| Provider Information | |||||||||
| NPI: | 1558359307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUNDAGE | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3276 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477313276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124730181 | ||||||||
| FaxNumber: | 8124735822 | ||||||||
| Practice Location | |||||||||
| Address1: | 7300 E INDIANA ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477152794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124018008 | ||||||||
| FaxNumber: | 8124018201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 00948 | IA | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 00435 | IA | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 20042407A | IN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | IA01K6 | 01 | JOHN DEERE HEALTH PLAN | OTHER | 0439240 | 05 | IA | MEDICAID | 34115 | 01 | IA | WELLMARK HEALTH PLAN | OTHER |