Healthcare Provider Details

I. General information

NPI: 1306342183
Provider Name (Legal Business Name): BRENNA A PEREZ OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4151 CAMINO COYOTE
LAS CRUCES NM
88011-7096
US

IV. Provider business mailing address

4151 CAMINO COYOTE
LAS CRUCES NM
88011-7096
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-0484
  • Fax: 575-522-0483
Mailing address:
  • Phone: 157-552-2048
  • Fax: 575-522-0483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3894
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: