Provider Demographics
NPI:1386246627
Name:BEAL, BRAELYN HATHAWAY (OTD)
Entity type:Individual
Prefix:
First Name:BRAELYN
Middle Name:HATHAWAY
Last Name:BEAL
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 LARCHMONT RD APT 236
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5972
Mailing Address - Country:US
Mailing Address - Phone:864-569-5695
Mailing Address - Fax:
Practice Address - Street 1:3905 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2517
Practice Address - Country:US
Practice Address - Phone:919-928-0204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NC16986225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst