Provider Demographics
NPI:1134960826
Name:COLLEBRUSCO, LAURA A (PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:COLLEBRUSCO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-8640
Mailing Address - Country:US
Mailing Address - Phone:307-739-7491
Mailing Address - Fax:307-739-1831
Practice Address - Street 1:555 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-739-7491
Practice Address - Fax:307-739-1831
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA124219225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist