Provider Demographics
NPI:1053437558
Name:KIRCHENBAUER, BRENDA LEIGH (OTR)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEIGH
Last Name:KIRCHENBAUER
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 1:4765 E PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-5763
Mailing Address - Country:US
Mailing Address - Phone:580-762-8199
Mailing Address - Fax:
Practice Address - Street 1:1900 N 14TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2035
Practice Address - Country:US
Practice Address - Phone:580-765-0518
Practice Address - Fax:580-765-0203
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK641225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist