Provider Demographics
NPI:1598132904
Name:BREITBACH, BRENDA DIANE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:DIANE
Last Name:BREITBACH
Suffix:
Gender:F
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 1:1115 4TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-2201
Mailing Address - Country:US
Mailing Address - Phone:320-258-8662
Mailing Address - Fax:320-258-9752
Practice Address - Street 1:1115 4TH AVE N
Practice Address - Street 2:
Practice Address - City:SAUK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56379-2201
Practice Address - Country:US
Practice Address - Phone:320-258-8662
Practice Address - Fax:320-258-9752
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103067225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist