Provider Demographics
NPI:1831133719
Name:SOUTHWELL, BRUCE CHESTER (PT)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:CHESTER
Last Name:SOUTHWELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7617 SYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-9517
Mailing Address - Country:US
Mailing Address - Phone:419-843-1402
Mailing Address - Fax:419-843-1407
Practice Address - Street 1:7617 SYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-9517
Practice Address - Country:US
Practice Address - Phone:419-843-1402
Practice Address - Fax:419-843-1407
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT6492225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH20372143500OtherBWC