Provider Demographics
NPI:1871826842
Name:BRUSUELAS, COY (FSS)
Entity Type:Individual
Prefix:
First Name:COY
Middle Name:
Last Name:BRUSUELAS
Suffix:
Gender:M
Credentials:FSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28220
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87592
Mailing Address - Country:US
Mailing Address - Phone:505-471-5006
Mailing Address - Fax:505-820-9220
Practice Address - Street 1:206 PORR DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345
Practice Address - Country:US
Practice Address - Phone:575-630-0571
Practice Address - Fax:575-630-0574
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NML7094Medicaid