Provider Demographics
NPI:1114385051
Name:BRUNS, DESERAE
Entity Type:Individual
Prefix:
First Name:DESERAE
Middle Name:
Last Name:BRUNS
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 1:527 S LONGBRACH DR
Mailing Address - Street 2:
Mailing Address - City:MAIZE
Mailing Address - State:KS
Mailing Address - Zip Code:67101
Mailing Address - Country:US
Mailing Address - Phone:316-708-4573
Mailing Address - Fax:
Practice Address - Street 1:2921 S MILLWOOD AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67217-2443
Practice Address - Country:US
Practice Address - Phone:316-708-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-07
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-04432224Z00000X
KS18-01315224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant