Provider Demographics
NPI:1952076333
Name:MUTERT, BRENDA LOU (LAT ATC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LOU
Last Name:MUTERT
Suffix:
Gender:F
Credentials:LAT ATC
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:LOU
Other - Last Name:KNIFFEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT ATC
Mailing Address - Street 1:879 E BARRACUDA DR
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-9158
Mailing Address - Country:US
Mailing Address - Phone:816-309-8259
Mailing Address - Fax:
Practice Address - Street 1:3545 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7310
Practice Address - Country:US
Practice Address - Phone:417-269-5530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150234362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer