Provider Demographics
NPI:1306588645
Name:BRUIN, CAROL ANN (PT, DPT, CSRS)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:ANN
Last Name:BRUIN
Suffix:
Gender:F
Credentials:PT, DPT, CSRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BUENO XING
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-7900
Mailing Address - Country:US
Mailing Address - Phone:859-619-7665
Mailing Address - Fax:
Practice Address - Street 1:4251 SARON DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40515-7005
Practice Address - Country:US
Practice Address - Phone:859-619-7665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006834225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty