MEDICARE: BRADY LYN AVINA 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	225X00000X	Occupational Therapist	OT010234	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OT010234	OTHER	OH	NATIONAL BOARD OF OCCUPATIONAL THERAPY

General Provider Information

NPI Number	:	1821578436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADY LYN AVINA OTR/L

Provider Business Mailing Address
First Line	:	PO BOX 53249
Second Line	:
City	:	PETTISVILLE
State	:	OH
Zip	:	43553-0249
Country	:	US
Telephone Number	:	419-822-7764
Fax Number	:

Provider Business Practice Location Address
First Line	:	214 S MUNSON RD
Second Line	:
City	:	SWANTON
State	:	OH
Zip	:	43558-1210
Country	:	US
Telephone Number	:	419-825-1145
Fax Number	:

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

Provider Enumeration Date	:	08/14/2018
Last Update Date	:	08/14/2018

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