Healthcare Provider Details

I. General information

NPI: 1275895393
Provider Name (Legal Business Name): BRENDA LEE WARDNER OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

596 SHELDON RD
SAINT ALBANS VT
05478-8011
US

IV. Provider business mailing address

1750 W BROADWAY ST STE 219
OVIEDO FL
32765-9618
US

V. Phone/Fax

Practice location:
  • Phone: 802-524-6534
  • Fax:
Mailing address:
  • Phone: 800-226-9917
  • Fax: 800-224-6215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number017073-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2500
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number10207
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number072.0099415
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: