Provider Demographics
NPI:1629588736
Name:BREZICKI, GAYLE S (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:GAYLE
Middle Name:S
Last Name:BREZICKI
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 KNOXVIEW LN
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9602
Mailing Address - Country:US
Mailing Address - Phone:704-778-6364
Mailing Address - Fax:
Practice Address - Street 1:1351 ROBINWOOD RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1693
Practice Address - Country:US
Practice Address - Phone:704-867-2319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11148224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant