Healthcare Provider Details

I. General information

NPI: 1518125350
Provider Name (Legal Business Name): BREENA COFFIELD RALEY MHS - OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 CENTRAL AVE STE C
AUGUSTA GA
30904-6246
US

IV. Provider business mailing address

207 4TH AVE
GROVETOWN GA
30813-2520
US

V. Phone/Fax

Practice location:
  • Phone: 706-364-6172
  • Fax: 706-262-2893
Mailing address:
  • Phone: 706-364-6172
  • Fax: 706-262-2893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: