MEDICARE: DR. NATHAN BRUSICH PSY. D.

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	103TC0700X	Clinical Psychologist	1247	OK

General Provider Information

NPI Number	:	1518339829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NATHAN BRUSICH PSY. D.

Provider Business Mailing Address
First Line	:	5230 E 69TH PL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-3407
Country	:	US
Telephone Number	:	918-280-0101
Fax Number	:	844-752-8249

Provider Business Practice Location Address
First Line	:	5230 E 69TH PL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-3407
Country	:	US
Telephone Number	:	918-280-0101
Fax Number	:	844-752-8249

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

Provider Enumeration Date	:	10/26/2015
Last Update Date	:	05/15/2016

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