Provider Demographics
NPI:1992007595
Name:BRUSSO, AMBER LYNNE (LMP)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LYNNE
Last Name:BRUSSO
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5621 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-6215
Mailing Address - Country:US
Mailing Address - Phone:253-222-5760
Mailing Address - Fax:
Practice Address - Street 1:5213 PACIFIC AVE STE 3
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7695
Practice Address - Country:US
Practice Address - Phone:253-474-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60069637225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist