Provider Demographics
NPI:1023277373
Name:BRACKEN, KANDY J (OT)
Entity type:Individual
Prefix:
First Name:KANDY
Middle Name:J
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 RANCH CLUB RD # 580
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7807
Mailing Address - Country:US
Mailing Address - Phone:360-477-7092
Mailing Address - Fax:
Practice Address - Street 1:4441 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8267
Practice Address - Country:US
Practice Address - Phone:575-521-6470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM707225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist