Provider Demographics
NPI:1114178894
Name:BRUTKO, KELLY (MSPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BRUTKO
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 WALDEN RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-4141
Mailing Address - Country:US
Mailing Address - Phone:570-592-4400
Mailing Address - Fax:
Practice Address - Street 1:900 TUCK ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7446
Practice Address - Country:US
Practice Address - Phone:717-273-8595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA010852L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist