Provider Demographics
NPI:1396305025
Name:MCCLINTOCK, BREANNA JEAN (OTA)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:JEAN
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 MAYFIELD DR UNIT 205
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50014-5582
Mailing Address - Country:US
Mailing Address - Phone:785-424-4266
Mailing Address - Fax:
Practice Address - Street 1:910 E OLIVE ST
Practice Address - Street 2:
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158-4175
Practice Address - Country:US
Practice Address - Phone:641-752-4581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-07-26
Deactivation Date:2019-06-21
Deactivation Code:
Reactivation Date:2019-07-26
Provider Licenses
StateLicense IDTaxonomies
IA090386224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant