Provider Demographics
NPI:1821141961
Name:BRUNDAGE, SUSAN R (DPT, MPT, OCS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:BRUNDAGE
Suffix:
Gender:F
Credentials:DPT, MPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6131
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:12402 INDUSTRIAL BLVD
Practice Address - Street 2:B2
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5871
Practice Address - Country:US
Practice Address - Phone:760-955-6061
Practice Address - Fax:760-955-6062
Is Sole Proprietor?:No
Enumeration Date:2007-01-20
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 28782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA72157585392277A003OtherTRICARE
CA0PT287820OtherBLUE SHIELD
WA218943OtherL & I WASHINGTON
CAPT0287820Medicaid
CA72157585392277A003OtherTRICARE
CAGS998ZMedicare PIN