Provider Demographics
NPI:1558664110
Name:FLETCHER-BRUSSEY, KIMBERLY LYNN
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LYNN
Last Name:FLETCHER-BRUSSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:LYNN
Other - Last Name:FLETCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:220 MILLIGAN RD
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-8212
Mailing Address - Country:US
Mailing Address - Phone:631-766-7153
Mailing Address - Fax:
Practice Address - Street 1:220 MILLIGAN RD
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-8212
Practice Address - Country:US
Practice Address - Phone:631-766-7153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013201-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist