Provider Demographics
NPI:1841769270
Name:CONAWAY, BRIAN BERNARD (OTR)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:BERNARD
Last Name:CONAWAY
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3113 PINOAK CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8911
Mailing Address - Country:US
Mailing Address - Phone:260-668-1691
Mailing Address - Fax:
Practice Address - Street 1:7125 S HANNA ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816
Practice Address - Country:US
Practice Address - Phone:260-668-1691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31001037A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist