Healthcare Provider Details

I. General information

NPI: 1134654072
Provider Name (Legal Business Name): BREANNA LEIGH DEKUIPER OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BREANNA LEIGH WOOD

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 DUNBAR CAVE RD STE A
CLARKSVILLE TN
37043-8850
US

IV. Provider business mailing address

5360 EDMONDSON PIKE APT 118
NASHVILLE TN
37211-7349
US

V. Phone/Fax

Practice location:
  • Phone: 931-233-9970
  • Fax:
Mailing address:
  • Phone: 615-294-3084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberAPPLIED FOR
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: