Provider Demographics
NPI:1851084776
Name:BRUSSEAU, KENDALL AUGUSTA (OT)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:AUGUSTA
Last Name:BRUSSEAU
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 ELM DR
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-2119
Mailing Address - Country:US
Mailing Address - Phone:208-245-4576
Mailing Address - Fax:208-245-2138
Practice Address - Street 1:617 S VANCOUVER ST # B
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-5140
Practice Address - Country:US
Practice Address - Phone:208-568-1194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-2328225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist