Provider Demographics
NPI:1518238658
Name:BRUCKER, KATHERINE HETTLEMAN (MPT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:HETTLEMAN
Last Name:BRUCKER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 ASHBURY CIR
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-3160
Mailing Address - Country:US
Mailing Address - Phone:239-558-8159
Mailing Address - Fax:
Practice Address - Street 1:216 SANTA BARBARA BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-2031
Practice Address - Country:US
Practice Address - Phone:239-242-8473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26334225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist