Provider Demographics
NPI:1962471953
Name:BRUNELLE, DONALD CHRISTOPHER (PT)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:CHRISTOPHER
Last Name:BRUNELLE
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 1:137 SILVER LEAF DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-7704
Mailing Address - Country:US
Mailing Address - Phone:229-439-4165
Mailing Address - Fax:
Practice Address - Street 1:130 E BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1809
Practice Address - Country:US
Practice Address - Phone:229-336-1115
Practice Address - Fax:229-336-1151
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0051782251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00107967OtherPALMETTO GBA - RR MEDICAR
GA00893846AMedicaid
GA65BBBKKMedicare ID - Type Unspecified
P00107967OtherPALMETTO GBA - RR MEDICAR