Provider Demographics
NPI:1730356510
Name:BRUNELLE, TOMMY JO (PT, DPT)
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:JO
Last Name:BRUNELLE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1673 W SHORELINE DR
Mailing Address - Street 2:STE 230
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6750
Mailing Address - Country:US
Mailing Address - Phone:208-343-4700
Mailing Address - Fax:208-343-4706
Practice Address - Street 1:1673 W SHORELINE DR
Practice Address - Street 2:STE 230
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6750
Practice Address - Country:US
Practice Address - Phone:208-343-4700
Practice Address - Fax:208-343-4706
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-374225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDTD785OtherBLUE CROSS