Healthcare Provider Details

I. General information

NPI: 1679853501
Provider Name (Legal Business Name): BRENDA KAY JERALD DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRENDA KAY MITCHELL DPT

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 N LAKEWOOD DR STE 101
COEUR D ALENE ID
83814-4928
US

IV. Provider business mailing address

1875 N LAKEWOOD DR STE 101
COEUR D ALENE ID
83814-4928
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-6264
  • Fax: 208-664-4313
Mailing address:
  • Phone: 208-667-6264
  • Fax: 208-664-4313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2889
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: