Provider Demographics
NPI:1477043354
Name:BRUNICK, KATHLEEN (OTR)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BRUNICK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6936 GARLAND LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-4642
Mailing Address - Country:US
Mailing Address - Phone:763-416-9313
Mailing Address - Fax:763-416-4530
Practice Address - Street 1:6936 GARLAND LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-4642
Practice Address - Country:US
Practice Address - Phone:763-416-9313
Practice Address - Fax:763-416-4530
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102791225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN102791OtherOCCUPATIONAL THERAPIST