Provider Demographics
NPI:1417297193
Name:BRUBAKER, LUTHGARDA STA MARIA (PT)
Entity type:Individual
Prefix:
First Name:LUTHGARDA
Middle Name:STA MARIA
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15606 HIGH BELL PL
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212-3911
Mailing Address - Country:US
Mailing Address - Phone:850-774-8429
Mailing Address - Fax:
Practice Address - Street 1:15606 HIGH BELL PL
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34212-3911
Practice Address - Country:US
Practice Address - Phone:850-774-8429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT27432225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002012700Medicaid
FL100313Medicare UPIN