Provider Demographics
NPI:1114098449
Name:BRUECK, CANDICE S (PT)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:S
Last Name:BRUECK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 MAIN STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:WINOOSKI
Mailing Address - State:VT
Mailing Address - Zip Code:05404
Mailing Address - Country:US
Mailing Address - Phone:802-864-3785
Mailing Address - Fax:802-864-0274
Practice Address - Street 1:321 MAIN STREET
Practice Address - Street 2:SUITE D
Practice Address - City:WINOOSKI
Practice Address - State:VT
Practice Address - Zip Code:05404
Practice Address - Country:US
Practice Address - Phone:802-864-3785
Practice Address - Fax:802-864-0274
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400003490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5270302OtherVMC EMI
06558898OtherBLUE CROSS
360645OtherMVP
360645OtherMVP