Provider Demographics
NPI:1407330178
Name:BREVOORT, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:BREVOORT
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 1:1778 ROBINWAY DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230-2240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 N COOPER AVE
Practice Address - Street 2:
Practice Address - City:LOCKLAND
Practice Address - State:OH
Practice Address - Zip Code:45215-3011
Practice Address - Country:US
Practice Address - Phone:513-563-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT006973225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty