Provider Demographics
NPI:1598382509
Name:DEEP-O'DONNELL, BROGAN ROSE (OTR/L)
Entity Type:Individual
Prefix:
First Name:BROGAN
Middle Name:ROSE
Last Name:DEEP-O'DONNELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:BROGAN
Other - Middle Name:
Other - Last Name:O'DONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:475 NORTHERN BLVD STE 19
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4802
Mailing Address - Country:US
Mailing Address - Phone:516-344-0023
Mailing Address - Fax:516-466-7723
Practice Address - Street 1:475 NORTHERN BLVD STE 19
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4802
Practice Address - Country:US
Practice Address - Phone:516-829-0030
Practice Address - Fax:516-466-7723
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024726252Y00000X, 251E00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No252Y00000XAgenciesEarly Intervention Provider Agency
No251E00000XAgenciesHome Health