Provider Demographics
NPI:1437556107
Name:FASS, BRACHA BAILA
Entity Type:Individual
Prefix:
First Name:BRACHA
Middle Name:BAILA
Last Name:FASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRACHA
Other - Middle Name:BAILA
Other - Last Name:FOGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1215 AVENUE M APT 4E
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-5226
Mailing Address - Country:US
Mailing Address - Phone:917-626-5173
Mailing Address - Fax:
Practice Address - Street 1:1215 AVENUE M APT 4E
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-5226
Practice Address - Country:US
Practice Address - Phone:917-626-5173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63019307225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist