Provider Demographics
NPI:1194485300
Name:YOUNG, BRENNA (COTA)
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 LOST TREE DR APT 3
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-8498
Mailing Address - Country:US
Mailing Address - Phone:417-337-2219
Mailing Address - Fax:
Practice Address - Street 1:1275 LOST TREE DR APT 3
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-8498
Practice Address - Country:US
Practice Address - Phone:417-337-2219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1794224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant