Provider Demographics
NPI:1104363100
Name:BRUNER, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:BRUNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3657 LONGBOW RD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-4442
Mailing Address - Country:US
Mailing Address - Phone:321-877-8590
Mailing Address - Fax:
Practice Address - Street 1:3657 LONGBOW RD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32926-4442
Practice Address - Country:US
Practice Address - Phone:321-877-8590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-27
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA9712224Z00000X, 390200000X
FLOT21708225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program