Provider Demographics
NPI:1710169347
Name:BRISSEL, MAGAN RENEE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:MAGAN
Middle Name:RENEE
Last Name:BRISSEL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1842 WILMA RUDOPH BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040
Mailing Address - Country:US
Mailing Address - Phone:931-906-0440
Mailing Address - Fax:931-920-5070
Practice Address - Street 1:1842 WILMA RUDOPH BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040
Practice Address - Country:US
Practice Address - Phone:931-906-0440
Practice Address - Fax:931-920-5070
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1573224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1573OtherLICENSE TN