Provider Demographics
NPI:1417591397
Name:MATHIS, BRANDI LYNN (COTA/L)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:LYNN
Last Name:MATHIS
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 1:2085 BLUESTONE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-6727
Mailing Address - Country:US
Mailing Address - Phone:636-896-0999
Mailing Address - Fax:
Practice Address - Street 1:2085 BLUESTONE DR STE 202
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-6727
Practice Address - Country:US
Practice Address - Phone:636-896-0999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017027209224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant