Provider Demographics
NPI:1730368994
Name:GELFUSO, BRENDA LEE (PTA)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LEE
Last Name:GELFUSO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3089 KING ROAD
Mailing Address - Street 2:
Mailing Address - City:SAUQUOIT
Mailing Address - State:NY
Mailing Address - Zip Code:13456
Mailing Address - Country:US
Mailing Address - Phone:315-796-3774
Mailing Address - Fax:
Practice Address - Street 1:3089 KING ROAD
Practice Address - Street 2:
Practice Address - City:SAUQUOIT
Practice Address - State:NY
Practice Address - Zip Code:13456
Practice Address - Country:US
Practice Address - Phone:315-796-3774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006105-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant