Provider Demographics
NPI:1144596297
Name:BRUTON, CHASE
Entity Type:Individual
Prefix:
First Name:CHASE
Middle Name:
Last Name:BRUTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-7152
Mailing Address - Country:US
Mailing Address - Phone:325-212-0170
Mailing Address - Fax:
Practice Address - Street 1:1629 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7152
Practice Address - Country:US
Practice Address - Phone:325-212-0170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXATP50901225CA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CA2400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX50901Medicaid