Provider Demographics
NPI:1184031494
Name:BRACKMAN, MINDA
Entity Type:Individual
Prefix:
First Name:MINDA
Middle Name:
Last Name:BRACKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 PEERY RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37082-8950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1070 PEERY RD
Practice Address - Street 2:
Practice Address - City:KINGSTON SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37082-8950
Practice Address - Country:US
Practice Address - Phone:615-952-3280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN869225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist