Provider Demographics
NPI:1811750946
Name:BRUCKS, PATRICIA
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BRUCKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93300 GRAVEL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:MI
Mailing Address - Zip Code:49065-8431
Mailing Address - Country:US
Mailing Address - Phone:708-705-8424
Mailing Address - Fax:
Practice Address - Street 1:93300 GRAVEL LAKE DR
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:MI
Practice Address - Zip Code:49065-8431
Practice Address - Country:US
Practice Address - Phone:708-705-8424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016920225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist