Provider Demographics
NPI:1699433110
Name:COSTELLO-BRUYER, EMMA M (MA)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:M
Last Name:COSTELLO-BRUYER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15412 E SPRAGUE AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99037-8841
Mailing Address - Country:US
Mailing Address - Phone:509-928-9098
Mailing Address - Fax:
Practice Address - Street 1:15412 E SPRAGUE AVE STE 8
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-8841
Practice Address - Country:US
Practice Address - Phone:509-928-9098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61214944225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist