Provider Demographics
NPI:1194935445
Name:BRUZZESE, SALVATORE
Entity type:Individual
Prefix:
First Name:SALVATORE
Middle Name:
Last Name:BRUZZESE
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 1:322 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2350
Mailing Address - Country:US
Mailing Address - Phone:860-395-3190
Mailing Address - Fax:860-395-3189
Practice Address - Street 1:322 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2350
Practice Address - Country:US
Practice Address - Phone:860-395-3190
Practice Address - Fax:860-395-3189
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000856101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional