Provider Demographics
NPI:1154890465
Name:BRUSASCO, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:BRUSASCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6341 4TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-6513
Mailing Address - Country:US
Mailing Address - Phone:360-989-4837
Mailing Address - Fax:
Practice Address - Street 1:6505 218TH ST SW STE 9
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2135
Practice Address - Country:US
Practice Address - Phone:206-388-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst