Provider Demographics
NPI:1750667523
Name:BRAREN-BACH, SUSAN ELLEN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ELLEN
Last Name:BRAREN-BACH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 RAY ST N
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-2337
Mailing Address - Country:US
Mailing Address - Phone:315-894-9855
Mailing Address - Fax:
Practice Address - Street 1:1 GOLDEN BOMBER DR
Practice Address - Street 2:
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-2600
Practice Address - Country:US
Practice Address - Phone:315-894-3210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001897-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist