Healthcare Provider Details

I. General information

NPI: 1316179237
Provider Name (Legal Business Name): BRENDA KIM RUWALDT OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRENDA KIM KING

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 W FRONT ST
TYLER TX
75702-7704
US

IV. Provider business mailing address

2323 W FRONT ST
TYLER TX
75702-7704
US

V. Phone/Fax

Practice location:
  • Phone: 903-597-1351
  • Fax: 903-535-7386
Mailing address:
  • Phone: 903-597-1351
  • Fax: 903-535-7386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number110069
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: