Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 1655 | AZ |
NPI | 1003145004 |
---|---|
Provider Name | Ms. Gloria Brandt |
First Address | Fountain Hills, AZ 85268-5440 |
Second Address | Tuba City, AZ 86045 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/12/2009 |
Last Update Date | 29/12/2009 |