Provider Demographics
NPI:1376511006
Name:BRUESEWITZ, MARK DAVID (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:BRUESEWITZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11331 SOUTH VIRGINIA STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511
Mailing Address - Country:US
Mailing Address - Phone:775-853-9966
Mailing Address - Fax:775-853-9969
Practice Address - Street 1:11331 SOUTH VIRGINIA STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511
Practice Address - Country:US
Practice Address - Phone:775-853-9966
Practice Address - Fax:775-853-9969
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0773225100000X
MN5136225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist