Provider Demographics
NPI:1578329934
Name:WILLOUGHBY, BRAXTON (OTR/L)
Entity Type:Individual
Prefix:
First Name:BRAXTON
Middle Name:
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 FLETCHER PL
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-1407
Mailing Address - Country:US
Mailing Address - Phone:718-215-4330
Mailing Address - Fax:
Practice Address - Street 1:491 FLETCHER PL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-1407
Practice Address - Country:US
Practice Address - Phone:718-215-4330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026455225XM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health