Provider Demographics
NPI:1508062985
Name:ROGERS, BRIENNE NICOLE (OTR/L, CLT)
Entity Type:Individual
Prefix:
First Name:BRIENNE
Middle Name:NICOLE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:OTR/L, CLT
Other - Prefix:
Other - First Name:BRIENNE
Other - Middle Name:NICOLE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-0130
Mailing Address - Country:US
Mailing Address - Phone:970-858-2186
Mailing Address - Fax:970-858-2208
Practice Address - Street 1:300 W OTTLEY AVE
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-2118
Practice Address - Country:US
Practice Address - Phone:970-858-2575
Practice Address - Fax:970-858-4569
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0003260225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4111589Medicaid