Provider Demographics
NPI:1154867711
Name:IRVING, BREONA PAIGE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:BREONA
Middle Name:PAIGE
Last Name:IRVING
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 1:280 DENMAN MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:GRAHAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12740-5507
Mailing Address - Country:US
Mailing Address - Phone:845-798-4027
Mailing Address - Fax:
Practice Address - Street 1:280 DENMAN MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:GRAHAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12740-5507
Practice Address - Country:US
Practice Address - Phone:845-798-4027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009020-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant