Provider Demographics
NPI:1679283980
Name:ROBERGE, BREYONNA (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:BREYONNA
Middle Name:
Last Name:ROBERGE
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3346 CENTURY DR
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-4151
Mailing Address - Country:US
Mailing Address - Phone:763-226-6661
Mailing Address - Fax:
Practice Address - Street 1:2101 WOODDALE DR STE A
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2933
Practice Address - Country:US
Practice Address - Phone:651-738-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107007225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist