Provider Demographics
NPI:1003408261
Name:MIFSUD, BRACHA (OTR)
Entity Type:Individual
Prefix:
First Name:BRACHA
Middle Name:
Last Name:MIFSUD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6417 ELRAY DR APT D
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-2928
Mailing Address - Country:US
Mailing Address - Phone:443-800-4106
Mailing Address - Fax:
Practice Address - Street 1:6202 GIST AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-3608
Practice Address - Country:US
Practice Address - Phone:410-292-8725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
MD09165225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist