Provider Demographics
NPI:1265452361
Name:BRUNSON, KELLY WHALEN (OTR)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:WHALEN
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:WHALEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:426 MCMILLEN ST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1996
Mailing Address - Country:US
Mailing Address - Phone:920-563-9357
Mailing Address - Fax:920-568-6545
Practice Address - Street 1:426 MCMILLEN ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1996
Practice Address - Country:US
Practice Address - Phone:920-563-9357
Practice Address - Fax:920-568-6545
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2477-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41030100Medicaid