Provider Demographics
NPI:1093468654
Name:BRUINHARD, TERESIA GRACHELLA
Entity Type:Individual
Prefix:
First Name:TERESIA
Middle Name:GRACHELLA
Last Name:BRUINHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7224 S ORA CT
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3033
Mailing Address - Country:US
Mailing Address - Phone:240-917-9121
Mailing Address - Fax:
Practice Address - Street 1:7224 S ORA CT
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3033
Practice Address - Country:US
Practice Address - Phone:240-917-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR03124225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty