Provider Demographics
NPI:1669879607
Name:CHITTHAM-BLEDSOE, PRUEKSA (OTR)
Entity type:Individual
Prefix:MRS
First Name:PRUEKSA
Middle Name:
Last Name:CHITTHAM-BLEDSOE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3827 MEADOW WAY TRL
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-1557
Mailing Address - Country:US
Mailing Address - Phone:816-806-3324
Mailing Address - Fax:
Practice Address - Street 1:3119 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4114
Practice Address - Country:US
Practice Address - Phone:816-806-3324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014028928225X00000X
NE2419225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist