Provider Demographics
NPI:1699416750
Name:GREENOUGH, BREANNE K
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:K
Last Name:GREENOUGH
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 1:10431 STATE ROUTE 22
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12832-5027
Mailing Address - Country:US
Mailing Address - Phone:518-538-4107
Mailing Address - Fax:
Practice Address - Street 1:10431 STATE ROUTE 22
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:NY
Practice Address - Zip Code:12832-5027
Practice Address - Country:US
Practice Address - Phone:518-538-4107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22-21052225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist