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General NPI Number Information
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NPI Number | 1548703937
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Entity Type | Individual
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Provider Name | BRADLEY JAMES RUSOVICK
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Gender | Male
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Dates
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Enumeration Date | 12/02/2016
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Last Update Date | 12/02/2016
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Provider Practice Location Address
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Address Line | 56 DUKE ST 200 WEST 'B' STREET, SUITE 226
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City | PUEBLO
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State | CO
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Zip | 81005-1604
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Country | US
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Telephone | 719-334-1010
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Fax |
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Provider Business Mailing Address
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Address Line | 5380 PEREGRINE DR
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City | PUEBLO
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State | CO
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Zip | 81005-5521
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Country | US
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Telephone | 719-334-1010
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | ACC0006272
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License Number State | CO
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