Provider Demographics
NPI:1124210075
Name:BRUNSON, REGINA SHERICE (PT)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:SHERICE
Last Name:BRUNSON
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 1:4312 SUGARSTONE LN APT 224
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-3247
Mailing Address - Country:US
Mailing Address - Phone:704-597-1262
Mailing Address - Fax:704-821-0570
Practice Address - Street 1:598 INDIAN TRAIL RD S STE 141
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-8689
Practice Address - Country:US
Practice Address - Phone:704-975-7008
Practice Address - Fax:704-821-0570
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10527225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist