Provider Demographics
NPI:1346407673
Name:CAUDLE, BREANNA (OTD- OT)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:CAUDLE
Suffix:
Gender:F
Credentials:OTD- OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 CIRCLE OF HOPE DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-5500
Mailing Address - Country:US
Mailing Address - Phone:314-703-1816
Mailing Address - Fax:
Practice Address - Street 1:1950 CIRCLE OF HOPE DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5500
Practice Address - Country:US
Practice Address - Phone:314-703-1816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
UT9383425-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health