Provider Demographics
NPI:1619519725
Name:BRUNSMANN, KYLE (MSR, LMT)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:
Last Name:BRUNSMANN
Suffix:
Gender:M
Credentials:MSR, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2706 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 LEBANON AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-4124
Practice Address - Country:US
Practice Address - Phone:618-619-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.020355225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist