Provider Demographics
NPI:1285894386
Name:BRAUNAGEL, RANDA JO (OTR)
Entity type:Individual
Prefix:
First Name:RANDA
Middle Name:JO
Last Name:BRAUNAGEL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5755 E STATE ROAD 244
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-8817
Mailing Address - Country:US
Mailing Address - Phone:317-797-8423
Mailing Address - Fax:765-525-9398
Practice Address - Street 1:5755 E STATE ROAD 244
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8817
Practice Address - Country:US
Practice Address - Phone:317-797-8423
Practice Address - Fax:765-525-9398
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31000175A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200612880Medicaid