Provider Demographics
NPI:1043295124
Name:BRESNAHAN, KEVIN ROBERT (PT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ROBERT
Last Name:BRESNAHAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 N EL CAMINO REAL
Mailing Address - Street 2:#210
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2811
Mailing Address - Country:US
Mailing Address - Phone:760-634-0248
Mailing Address - Fax:760-634-1782
Practice Address - Street 1:10225 AUSTIN DRIVE
Practice Address - Street 2:# 204
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91978
Practice Address - Country:US
Practice Address - Phone:619-670-4567
Practice Address - Fax:619-670-0200
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 14228225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT14228AMedicare PIN