Healthcare Provider Details

I. General information

NPI: 1235633355
Provider Name (Legal Business Name): TERRENA GRACE VIGIL BRADY OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 YALE BLVD
ALBUQUERQUE NM
87106
US

IV. Provider business mailing address

1001 YALE BLVD
ALBUQUERQUE NM
87106
US

V. Phone/Fax

Practice location:
  • Phone: 303-704-2361
  • Fax:
Mailing address:
  • Phone: 303-704-2361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number7402
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT3919
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: