Provider Demographics
NPI:1891832515
Name:CLEVELAND, BRANDIE LEA (OTA)
Entity Type:Individual
Prefix:
First Name:BRANDIE
Middle Name:LEA
Last Name:CLEVELAND
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15176 R ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-2470
Mailing Address - Country:US
Mailing Address - Phone:402-331-4341
Mailing Address - Fax:402-398-3955
Practice Address - Street 1:1540 N 72ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-1924
Practice Address - Country:US
Practice Address - Phone:402-398-3958
Practice Address - Fax:402-398-3955
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE722224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-0707622-01Medicaid
NE47-0707622-01Medicaid