Provider Demographics
NPI:1669788386
Name:BRUSO, JOAN THERESA (OTR)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:THERESA
Last Name:BRUSO
Suffix:
Gender:F
Credentials:OTR
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 6622
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85312-6622
Mailing Address - Country:US
Mailing Address - Phone:602-910-1996
Mailing Address - Fax:623-934-3887
Practice Address - Street 1:4494 W PEORIA AVE
Practice Address - Street 2:SUITE 115 B
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-2023
Practice Address - Country:US
Practice Address - Phone:602-910-1996
Practice Address - Fax:623-934-3887
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0781225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist