Provider Demographics
NPI:1740417732
Name:BRUSSOW, BACH-TUYET THI
Entity Type:Individual
Prefix:
First Name:BACH-TUYET
Middle Name:THI
Last Name:BRUSSOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9621 MYRTLE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-5905
Mailing Address - Country:US
Mailing Address - Phone:407-529-4711
Mailing Address - Fax:
Practice Address - Street 1:9621 MYRTLE CREEK LN
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-5905
Practice Address - Country:US
Practice Address - Phone:407-529-4711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8568235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist