Healthcare Provider Details

I. General information

NPI: 1992929582
Provider Name (Legal Business Name): KEVIN JON BRUSSE P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2629 N 7TH ST
SHEBOYGAN WI
53083-4932
US

IV. Provider business mailing address

1099 CREEKS CROSS CT
KOHLER WI
53044-1347
US

V. Phone/Fax

Practice location:
  • Phone: 920-451-5000
  • Fax:
Mailing address:
  • Phone: 920-208-8670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9888-024
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number9888
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number9888
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: