Provider Demographics
NPI:1083277222
Name:KALANISH, BREANNA MARIE (COTA/L)
Entity Type:Individual
Prefix:MISS
First Name:BREANNA
Middle Name:MARIE
Last Name:KALANISH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20909 PLEASANT VIEW LN SW
Mailing Address - Street 2:
Mailing Address - City:RAWLINGS
Mailing Address - State:MD
Mailing Address - Zip Code:21557-2508
Mailing Address - Country:US
Mailing Address - Phone:301-357-0376
Mailing Address - Fax:
Practice Address - Street 1:1543 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1306
Practice Address - Country:US
Practice Address - Phone:304-363-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-14
Last Update Date:2019-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC2264224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant