Provider Demographics
NPI:1770673089
Name:HUDDLESTON, BRUCE A (OTR/L)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:HUDDLESTON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4608 W NIXON ST
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-2834
Mailing Address - Country:US
Mailing Address - Phone:239-770-7612
Mailing Address - Fax:
Practice Address - Street 1:4608 W NIXON ST
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-2834
Practice Address - Country:US
Practice Address - Phone:239-770-7612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2011-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8373225XP0200X
WA00003987225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891065100Medicaid