Provider Demographics
NPI:1063041945
Name:BRUNER, TIMOTHY WILLIAM (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WILLIAM
Last Name:BRUNER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-1234
Mailing Address - Country:US
Mailing Address - Phone:717-599-9033
Mailing Address - Fax:
Practice Address - Street 1:770 LIGHTHOUSE DR UNIT 170
Practice Address - Street 2:
Practice Address - City:BARNEGAT
Practice Address - State:NJ
Practice Address - Zip Code:08005-2373
Practice Address - Country:US
Practice Address - Phone:609-698-1073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01918600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist