Provider Demographics
NPI:1548703937
Name:RUSOVICK, BRADLEY JAMES
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JAMES
Last Name:RUSOVICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5380 PEREGRINE DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-5521
Mailing Address - Country:US
Mailing Address - Phone:719-334-1010
Mailing Address - Fax:
Practice Address - Street 1:56 DUKE ST
Practice Address - Street 2:200 WEST 'B' STREET, SUITE 226
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-1604
Practice Address - Country:US
Practice Address - Phone:719-334-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC0006272101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)