Provider Demographics
NPI:1932309861
Name:BRUNKHORST, LORA (COTA)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:
Last Name:BRUNKHORST
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 RAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IA
Mailing Address - Zip Code:50633-7540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 E J AVE
Practice Address - Street 2:
Practice Address - City:GRUNDY CENTER
Practice Address - State:IA
Practice Address - Zip Code:50638-2031
Practice Address - Country:US
Practice Address - Phone:319-824-5683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00637224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant