Provider Demographics
NPI:1962985895
Name:BRAGAN, BREANNA JANEL (MSOTR/L)
Entity type:Individual
Prefix:MRS
First Name:BREANNA
Middle Name:JANEL
Last Name:BRAGAN
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:MS
Other - First Name:BREANNA
Other - Middle Name:JANEL
Other - Last Name:RANDOLPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSOTR/L
Mailing Address - Street 1:31 BRUNSWICK ST
Mailing Address - Street 2:
Mailing Address - City:OLD TOWN
Mailing Address - State:ME
Mailing Address - Zip Code:04468-1445
Mailing Address - Country:US
Mailing Address - Phone:207-540-6678
Mailing Address - Fax:
Practice Address - Street 1:36 WORKMAN TER
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ME
Practice Address - Zip Code:04457-1162
Practice Address - Country:US
Practice Address - Phone:207-794-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT3356225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist