Provider Demographics
NPI:1033723234
Name:PRUSAS, JOSEPH IV (MA CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:PRUSAS
Suffix:IV
Gender:M
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 BRIARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-5937
Mailing Address - Country:US
Mailing Address - Phone:321-222-0705
Mailing Address - Fax:
Practice Address - Street 1:124 BRIARWOOD LN
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32926-5937
Practice Address - Country:US
Practice Address - Phone:321-698-7639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10232235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist