Provider Demographics
NPI:1942571195
Name:BRAESCH, BARRY LEE (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:BARRY
Middle Name:LEE
Last Name:BRAESCH
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 N 93RD ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-3937
Mailing Address - Country:US
Mailing Address - Phone:402-630-0905
Mailing Address - Fax:
Practice Address - Street 1:2525 S 135TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2424
Practice Address - Country:US
Practice Address - Phone:402-333-2304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE311224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant