Provider Demographics
NPI:1235633355
Name:VIGIL BRADY, TERRENA GRACE (OTR/L)
Entity Type:Individual
Prefix:
First Name:TERRENA
Middle Name:GRACE
Last Name:VIGIL BRADY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 YALE BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106
Mailing Address - Country:US
Mailing Address - Phone:303-704-2361
Mailing Address - Fax:
Practice Address - Street 1:1001 YALE BLVD
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:303-704-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7402225X00000X
NMOT3919225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist