Basic Information
| Provider Information | |||||||||
| NPI: | 1588188858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULETZA | ||||||||
| FirstName: | BRIEANN | ||||||||
| MiddleName: | N | ||||||||
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| OtherLastName: | SHIPKOWSKI | ||||||||
| OtherFirstName: | BRIEANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7 DOCK HILL RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178428910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708372123 | ||||||||
| FaxNumber: | 5708372185 | ||||||||
| Practice Location | |||||||||
| Address1: | 4830 LONDONDERRY RD | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171095207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177244888 | ||||||||
| FaxNumber: | 7176524203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2017 | ||||||||
| LastUpdateDate: | 02/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT026303 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1033331020003 | 05 | PA | MEDICAID |