Provider Demographics
NPI:1376778357
Name:BRUNSON, MICHELLE ELIZABETH (DPT)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:ELIZABETH
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 LOWER HUNTINGTON RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46819-1355
Mailing Address - Country:US
Mailing Address - Phone:336-263-8216
Mailing Address - Fax:
Practice Address - Street 1:3844 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1724
Practice Address - Country:US
Practice Address - Phone:260-483-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009796A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist