Provider Demographics
NPI:1659609584
Name:BRADY, REBECCA L (APRN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:BRADY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 WOODS HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WEST SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06093-2656
Mailing Address - Country:US
Mailing Address - Phone:860-983-0580
Mailing Address - Fax:
Practice Address - Street 1:49 WOODS HOLLOW RD
Practice Address - Street 2:
Practice Address - City:WEST SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06093-2656
Practice Address - Country:US
Practice Address - Phone:860-983-0580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT20163920363LP0808X, 364SP0810X
CT004231363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Family
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004231OtherAPRN CT STATE LISCENSURE