Provider Demographics
NPI:1093118374
Name:PRUSOCK, JULIE ANN (AT)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:PRUSOCK
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9309 DEWEY RD
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44094-5173
Mailing Address - Country:US
Mailing Address - Phone:440-729-7055
Mailing Address - Fax:
Practice Address - Street 1:9309 DEWEY RD
Practice Address - Street 2:
Practice Address - City:KIRTLAND
Practice Address - State:OH
Practice Address - Zip Code:44094-5173
Practice Address - Country:US
Practice Address - Phone:216-402-3495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT-0013302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer