Provider Demographics
NPI:1093994261
Name:BRUNGARDT, JANELLE RAE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:JANELLE
Middle Name:RAE
Last Name:BRUNGARDT
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2241 NORTHWEST STREET
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401
Mailing Address - Country:US
Mailing Address - Phone:712-792-9284
Mailing Address - Fax:
Practice Address - Street 1:2241 NORTHWEST STREET
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401
Practice Address - Country:US
Practice Address - Phone:712-792-9284
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
IA000777224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant