Provider Demographics
NPI:1871668350
Name:PRUNISKI, MIMI (OTL)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:
Last Name:PRUNISKI
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8521 W CHERRY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-8170
Mailing Address - Country:US
Mailing Address - Phone:623-487-8616
Mailing Address - Fax:
Practice Address - Street 1:8521 W CHERRY HILLS DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-8170
Practice Address - Country:US
Practice Address - Phone:623-487-8616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ516225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics