Provider Demographics
NPI:1528189362
Name:BRUNELLE, BRYAN MICHAEL (PT, DPT, OCS, CEAS)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:MICHAEL
Last Name:BRUNELLE
Suffix:
Gender:M
Credentials:PT, DPT, OCS, CEAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 E FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-1640
Mailing Address - Country:US
Mailing Address - Phone:443-827-8649
Mailing Address - Fax:410-554-6687
Practice Address - Street 1:3333 N CALVERT ST STE 200
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-6505
Practice Address - Country:US
Practice Address - Phone:410-554-2107
Practice Address - Fax:410-554-6687
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21981225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist