Provider Demographics
NPI:1841758547
Name:BUSSELL, ERIN BROOKE (PTA)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:BROOKE
Last Name:BUSSELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27299 RIVERVIEW CENTER BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4322
Mailing Address - Country:US
Mailing Address - Phone:239-676-2080
Mailing Address - Fax:239-676-2089
Practice Address - Street 1:2619 FORUM BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-5605
Practice Address - Country:US
Practice Address - Phone:239-673-3414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA25120225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant