Provider Demographics
NPI:1710411491
Name:BRAZALOVICH, PHILIP JOSEPH JR (ATC)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:JOSEPH
Last Name:BRAZALOVICH
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 TALCOTT RD
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2919
Mailing Address - Country:US
Mailing Address - Phone:860-712-8466
Mailing Address - Fax:
Practice Address - Street 1:1824 PARKFORD LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-7084
Practice Address - Country:US
Practice Address - Phone:860-712-8466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0011432255A2300X
OHAT0053822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer