Provider Demographics
NPI:1104262534
Name:BRUNT, ANGELA M (COTA/L)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:BRUNT
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23178 REBECCA DR
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46517-9172
Mailing Address - Country:US
Mailing Address - Phone:574-215-8446
Mailing Address - Fax:
Practice Address - Street 1:3801 OLD BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-3889
Practice Address - Country:US
Practice Address - Phone:812-886-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002423A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant