Provider Demographics
NPI:1407902281
Name:BRICKENDEN, GLORIA D (MA, OTR/L)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:D
Last Name:BRICKENDEN
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2736 HOLLYWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-4808
Mailing Address - Country:US
Mailing Address - Phone:954-603-1881
Mailing Address - Fax:
Practice Address - Street 1:2736 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-4808
Practice Address - Country:US
Practice Address - Phone:954-603-1881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT8580225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884789400Medicaid