Provider Demographics
NPI:1619493483
Name:BRUBAKER, GRETCHEN ANNE (MOT, OTR/L, MCIS)
Entity Type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:ANNE
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:MOT, OTR/L, MCIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 JUNIPER ST
Mailing Address - Street 2:
Mailing Address - City:HOMER CITY
Mailing Address - State:PA
Mailing Address - Zip Code:15748-1507
Mailing Address - Country:US
Mailing Address - Phone:724-915-8176
Mailing Address - Fax:
Practice Address - Street 1:88 JUNIPER ST
Practice Address - Street 2:
Practice Address - City:HOMER CITY
Practice Address - State:PA
Practice Address - Zip Code:15748-1507
Practice Address - Country:US
Practice Address - Phone:724-915-8176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC012553225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1033318880001Medicaid