Provider Demographics
NPI:1558667428
Name:GOTTWALD, BREEYA (OTR/L)
Entity Type:Individual
Prefix:
First Name:BREEYA
Middle Name:
Last Name:GOTTWALD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:BREEYA
Other - Middle Name:
Other - Last Name:MARTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:PO BOX 691
Mailing Address - Street 2:
Mailing Address - City:GARBERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95542-0691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1013 TOTH RD
Practice Address - Street 2:MOBILE-TRAVEL TO PATIENT HOME
Practice Address - City:WHITETHORN
Practice Address - State:CA
Practice Address - Zip Code:95589-9017
Practice Address - Country:US
Practice Address - Phone:916-801-1570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10564225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist