Provider Demographics
NPI:1093825036
Name:ELLIOTT, BRUCE NICHOLAS (PT)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:NICHOLAS
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 LIBERTY HWY
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-2720
Mailing Address - Country:US
Mailing Address - Phone:860-928-2509
Mailing Address - Fax:
Practice Address - Street 1:843 BOLTON RD
Practice Address - Street 2:U-1249
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06269-9020
Practice Address - Country:US
Practice Address - Phone:860-486-8080
Practice Address - Fax:860-486-8081
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist