Provider Demographics
NPI:1316231988
Name:STICE, BREANNA DAWN (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:BREANNA
Middle Name:DAWN
Last Name:STICE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MISS
Other - First Name:BREANNA
Other - Middle Name:DAWN
Other - Last Name:SMERLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:PO BOX 6642
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73153-0642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6400 N. SANTA FE
Practice Address - Street 2:SUITE B
Practice Address - City:OKC
Practice Address - State:OK
Practice Address - Zip Code:73116-9111
Practice Address - Country:US
Practice Address - Phone:405-840-2903
Practice Address - Fax:405-840-3256
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK956224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant