Provider Demographics
NPI:1790305092
Name:TRICE, BREONA
Entity Type:Individual
Prefix:
First Name:BREONA
Middle Name:
Last Name:TRICE
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 1:6809 YAZOO ST APT 107
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-4024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4711 S HURSTBOURNE PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-7202
Practice Address - Country:US
Practice Address - Phone:502-873-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist