Provider Demographics
NPI:1316203201
Name:BRANTLEY, REGINA GERTRUDE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:REGINA
Middle Name:GERTRUDE
Last Name:BRANTLEY
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 1:161 SUNRISE CT
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-8057
Mailing Address - Country:US
Mailing Address - Phone:870-424-0909
Mailing Address - Fax:
Practice Address - Street 1:161 SUNRISE CT
Practice Address - Street 2:
Practice Address - City:MTN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653
Practice Address - Country:US
Practice Address - Phone:870-424-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A338224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant