Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 3067 | TN |
NPI | 1023674223 |
---|---|
Provider Name | Victoria Brake |
First Address | Bumpus Mills, TN 37028-6024 |
Second Address | Bumpus Mills, TN 37028-6024 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/05/2019 |
Last Update Date | 13/05/2019 |