Provider Demographics
NPI:1003647074
Name:BRNCICH, BREENA RAE (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:BREENA
Middle Name:RAE
Last Name:BRNCICH
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27425 S WILL RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60481-8352
Mailing Address - Country:US
Mailing Address - Phone:815-693-9612
Mailing Address - Fax:
Practice Address - Street 1:3002 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:DIAMOND
Practice Address - State:IL
Practice Address - Zip Code:60416-9486
Practice Address - Country:US
Practice Address - Phone:815-390-5366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.016146225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics