Provider Demographics
NPI:1851438980
Name:RUTHERFORD, BRENDA LOU (OTR)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LOU
Last Name:RUTHERFORD
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 1:437 FOX RUN
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-4622
Mailing Address - Country:US
Mailing Address - Phone:386-668-7899
Mailing Address - Fax:
Practice Address - Street 1:437 FOX RUN
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-4622
Practice Address - Country:US
Practice Address - Phone:407-453-2885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 976225XP0200X
FL976225X00000X
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
FL880177100Medicaid