Provider Demographics
NPI:1518339829
Name:BRUSICH, NATHAN (PSY D)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:BRUSICH
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5230 E 69TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3407
Mailing Address - Country:US
Mailing Address - Phone:918-280-0101
Mailing Address - Fax:844-752-8249
Practice Address - Street 1:5230 E 69TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3407
Practice Address - Country:US
Practice Address - Phone:918-280-0101
Practice Address - Fax:844-752-8249
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2016-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1247103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical