MEDICARE: BREENA RAE BRNCICH OTD, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	056.016146	IL

General Provider Information

NPI Number	:	1003647074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREENA RAE BRNCICH OTD, OTR/L

Provider Business Mailing Address
First Line	:	27425 S WILL RD
Second Line	:
City	:	WILMINGTON
State	:	IL
Zip	:	60481-8352
Country	:	US
Telephone Number	:	815-693-9612
Fax Number	:

Provider Business Practice Location Address
First Line	:	3002 E DIVISION ST
Second Line	:
City	:	DIAMOND
State	:	IL
Zip	:	60416-9486
Country	:	US
Telephone Number	:	815-390-5366
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2024
Last Update Date	:	08/12/2024

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