Provider Demographics
NPI:1659497089
Name:BRAYTON, MARY R (MS, OTR)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:BRAYTON
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N6291 STATE HIGHWAY 55
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54491-9632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2710
Practice Address - Country:US
Practice Address - Phone:715-623-9469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1737-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40611300Medicaid
WI1737-026OtherOT STATE LICENSURE