Provider Demographics
NPI:1134654072
Name:DEKUIPER, BREANNA LEIGH (OTD)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:LEIGH
Last Name:DEKUIPER
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:LEIGH
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5360 EDMONDSON PIKE
Mailing Address - Street 2:APT 118
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-7349
Mailing Address - Country:US
Mailing Address - Phone:615-294-3084
Mailing Address - Fax:
Practice Address - Street 1:215 DUNBAR CAVE RD STE A
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8850
Practice Address - Country:US
Practice Address - Phone:931-233-9970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
TNAPPLIED FOR225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist