Provider Demographics
NPI:1407913627
Name:BRAKE, CONSTANCE MARIE (MS OTRL)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:MARIE
Last Name:BRAKE
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 PARK BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-2042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5415 W FRIENDLY AVE STE A
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-4255
Practice Address - Country:US
Practice Address - Phone:336-772-5499
Practice Address - Fax:336-292-6064
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4237225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13740OtherBLUE CROSS AND BLUE SHIEL
NC7301713Medicaid