Provider Demographics
NPI:1053432906
Name:BRUS, WENDY ELLEN (MSW)
Entity type:Individual
Prefix:MS
First Name:WENDY
Middle Name:ELLEN
Last Name:BRUS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:WENDY
Other - Middle Name:BRUS
Other - Last Name:FALLON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:805 FARMINGTON AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1670
Mailing Address - Country:US
Mailing Address - Phone:860-232-2801
Mailing Address - Fax:860-232-2801
Practice Address - Street 1:805 FARMINGTON AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1670
Practice Address - Country:US
Practice Address - Phone:860-232-2801
Practice Address - Fax:860-232-2801
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000479101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCT 000479OtherLICENSE NUMBER
136340OtherVALUE OPTIONS PROVIDER
45726OtherCIGNA BEHAVIORAL PROVIDER