Healthcare Provider Details

I. General information

NPI: 1003146911
Provider Name (Legal Business Name): KAITLIN ELIZABETH BRUNSVOLD M.S. OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAITLIN ELIZABETH KIERAS

II. Dates (important events)

Enumeration Date: 12/28/2009
Last Update Date: 08/28/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 N CLARK ST.
CHICAGO IL
60614
US

IV. Provider business mailing address

333 S. DESPLAINES ST #606
CHICAGO IL
60661-5509
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-4000
  • Fax:
Mailing address:
  • Phone: 248-425-4968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056008883
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056008883
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: