Provider Demographics
NPI:1144773672
Name:BRESKE, RANDAL JAMES (COTA/L)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:JAMES
Last Name:BRESKE
Suffix:
Gender:M
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 1:1401 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57274-1054
Mailing Address - Country:US
Mailing Address - Phone:605-588-3186
Mailing Address - Fax:
Practice Address - Street 1:1401 W 1ST ST
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:SD
Practice Address - Zip Code:57274-1054
Practice Address - Country:US
Practice Address - Phone:605-588-3186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD128A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant