Provider Demographics
NPI:1629137864
Name:BRINEGAR, DEIDRE DALE
Entity Type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:DALE
Last Name:BRINEGAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 HIGHWAY AA
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63384-3706
Mailing Address - Country:US
Mailing Address - Phone:573-581-3000
Mailing Address - Fax:573-581-0888
Practice Address - Street 1:222 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-2821
Practice Address - Country:US
Practice Address - Phone:573-581-3000
Practice Address - Fax:573-581-0888
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001016829225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist