Healthcare Provider Details

I. General information

NPI: 1326642216
Provider Name (Legal Business Name): MISS MYA J BRATHWAITE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date: 11/07/2024
Reactivation Date: 11/26/2024

III. Provider practice location address

130 CONDOR ST
EAST BOSTON MA
02128-1305
US

IV. Provider business mailing address

102 BROOK ST
QUINCY MA
02170-1508
US

V. Phone/Fax

Practice location:
  • Phone: 617-569-6560
  • Fax:
Mailing address:
  • Phone: 781-640-0657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number15546
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: