Provider Demographics
NPI:1730815671
Name:BAGOZZI, BRIELLE DOMINIQUE
Entity type:Individual
Prefix:
First Name:BRIELLE
Middle Name:DOMINIQUE
Last Name:BAGOZZI
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 1:119 LAKEWOOD PINES TRL
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13209-1161
Mailing Address - Country:US
Mailing Address - Phone:315-447-7761
Mailing Address - Fax:
Practice Address - Street 1:119 LAKEWOOD PINES TRL
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13209-1161
Practice Address - Country:US
Practice Address - Phone:315-447-7761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-25
Last Update Date:2025-10-06
Deactivation Date:2025-09-11
Deactivation Code:
Reactivation Date:2025-10-06
Provider Licenses
StateLicense IDTaxonomies
NY0049952255A2300X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer