Provider Demographics
NPI:1740352475
Name:BRUSO, JEANNETTA DIANE (MA CCC SLP)
Entity type:Individual
Prefix:
First Name:JEANNETTA
Middle Name:DIANE
Last Name:BRUSO
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24054 WELDON DR
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32736-7924
Mailing Address - Country:US
Mailing Address - Phone:321-292-4611
Mailing Address - Fax:
Practice Address - Street 1:24054 WELDON DR
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32736-7924
Practice Address - Country:US
Practice Address - Phone:321-292-4611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2104235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist