Provider Demographics
NPI:1053494443
Name:BRUSAW, JULIE ANN (MA LCPC LMFT)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANN
Last Name:BRUSAW
Suffix:
Gender:F
Credentials:MA LCPC LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10561 SAGLE RD
Mailing Address - Street 2:
Mailing Address - City:SAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83860-8836
Mailing Address - Country:US
Mailing Address - Phone:208-255-9277
Mailing Address - Fax:208-255-1254
Practice Address - Street 1:1035 BALDY MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-9250
Practice Address - Country:US
Practice Address - Phone:208-255-9277
Practice Address - Fax:208-255-1254
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-2639101YP2500X
IDLMFT-2640106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ3261OtherBLUE CROSS
WA154413OtherFIRST CHOICE HEALTH
ID0000101038597OtherREGENCE BLUE SHIELD
CA154413OtherMHN