MEDICARE: MISS MICHELLE ELIZABETH BRUNSON DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	05009796A	IN

General Provider Information

NPI Number	:	1376778357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MICHELLE ELIZABETH BRUNSON DPT

Provider Business Mailing Address
First Line	:	1229 LOWER HUNTINGTON RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46819-1355
Country	:	US
Telephone Number	:	336-263-8216
Fax Number	:

Provider Business Practice Location Address
First Line	:	3844 NEW VISION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1724
Country	:	US
Telephone Number	:	260-483-9933
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2009
Last Update Date	:	07/15/2009

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