Provider Demographics
NPI:1073604344
Name:BRUNS, SANDRA SKELLIE (OT/L)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:SKELLIE
Last Name:BRUNS
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 VINCA CIR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-5755
Mailing Address - Country:US
Mailing Address - Phone:828-273-1334
Mailing Address - Fax:
Practice Address - Street 1:4201 LAKE BOONE TRL STE 4
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7511
Practice Address - Country:US
Practice Address - Phone:919-781-4434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0022225XP0200X, 225X00000X
NC22225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301925Medicaid
NC190695OtherMEDCOST
NC1426YOtherBCBSNC