Provider Demographics
NPI:1619978244
Name:BRUN, THERESA M (MPT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:BRUN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:M
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:420 BAINBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1568
Mailing Address - Country:US
Mailing Address - Phone:215-629-1270
Mailing Address - Fax:215-629-5531
Practice Address - Street 1:9379 KREWSTOWN RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3710
Practice Address - Country:US
Practice Address - Phone:215-676-6760
Practice Address - Fax:215-676-3746
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015824174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist