Provider Demographics
NPI:1487021564
Name:BRUERE, KERSTIN AUTUMN
Entity Type:Individual
Prefix:
First Name:KERSTIN
Middle Name:AUTUMN
Last Name:BRUERE
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 1:125 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1877
Mailing Address - Country:US
Mailing Address - Phone:217-479-4232
Mailing Address - Fax:217-479-4328
Practice Address - Street 1:125 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1877
Practice Address - Country:US
Practice Address - Phone:217-479-4232
Practice Address - Fax:217-479-4328
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist