Provider Demographics
NPI:1316179237
Name:RUWALDT, BRENDA KIM (OT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:KIM
Last Name:RUWALDT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:KIM
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2323 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-7704
Mailing Address - Country:US
Mailing Address - Phone:903-597-1351
Mailing Address - Fax:903-535-7386
Practice Address - Street 1:2323 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-7704
Practice Address - Country:US
Practice Address - Phone:903-597-1351
Practice Address - Fax:903-535-7386
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110069225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist