Provider Demographics
NPI:1578656252
Name:BRUZZESE, ROBERT THOMAS (LICSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:THOMAS
Last Name:BRUZZESE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:589 BROADWAY
Mailing Address - Street 2:APT. D
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151
Mailing Address - Country:US
Mailing Address - Phone:508-330-1053
Mailing Address - Fax:
Practice Address - Street 1:589 BROADWAY
Practice Address - Street 2:APT. D
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151
Practice Address - Country:US
Practice Address - Phone:508-330-1053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101048104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker