Provider Demographics
NPI:1225797129
Name:THEBEAU, BRENDA KAY
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:THEBEAU
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 1:3761 E US HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:LINN CREEK
Mailing Address - State:MO
Mailing Address - Zip Code:65052-1756
Mailing Address - Country:US
Mailing Address - Phone:314-808-3955
Mailing Address - Fax:
Practice Address - Street 1:3761 E US HIGHWAY 54
Practice Address - Street 2:
Practice Address - City:LINN CREEK
Practice Address - State:MO
Practice Address - Zip Code:65052-1756
Practice Address - Country:US
Practice Address - Phone:314-808-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005389224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant