Healthcare Provider Details

I. General information

NPI: 1336930965
Provider Name (Legal Business Name): BRAIN EXECUTIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2025
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7847 MIDDAY LN
ALEXANDRIA VA
22306-2723
US

IV. Provider business mailing address

16366 N SHORE DR
PENSACOLA FL
32507-8372
US

V. Phone/Fax

Practice location:
  • Phone: 757-633-8940
  • Fax:
Mailing address:
  • Phone: 757-633-8940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN ANN HAMLIN-PACHECO
Title or Position: OWNER
Credential: OTR/L
Phone: 757-633-8940