Provider Demographics
NPI:1225690514
Name:BRUSKEVITH, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:BRUSKEVITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4834 AUGUSTA AVE
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-6329
Mailing Address - Country:US
Mailing Address - Phone:814-490-1381
Mailing Address - Fax:
Practice Address - Street 1:3491 GANDY BLVD N STE 201
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-2654
Practice Address - Country:US
Practice Address - Phone:440-299-8184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker