Provider Demographics
NPI:1619604097
Name:BOYER, BREANNA (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:BREANNA
Middle Name:
Last Name:BOYER
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 1:1495 CASA BUENA DR APT 406
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1753
Mailing Address - Country:US
Mailing Address - Phone:805-264-7390
Mailing Address - Fax:
Practice Address - Street 1:1465 S NOVATO BLVD
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-4509
Practice Address - Country:US
Practice Address - Phone:119-299-2926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23939225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist