Provider Demographics
NPI:1295992147
Name:BRAET, TANYA JO (MOT, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:JO
Last Name:BRAET
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5939 DAYTON CORNER B ST
Mailing Address - Street 2:
Mailing Address - City:COLONA
Mailing Address - State:IL
Mailing Address - Zip Code:61241-8924
Mailing Address - Country:US
Mailing Address - Phone:309-792-2426
Mailing Address - Fax:
Practice Address - Street 1:5939 DAYTON CORNER B ST
Practice Address - Street 2:
Practice Address - City:COLONA
Practice Address - State:IL
Practice Address - Zip Code:61241-8924
Practice Address - Country:US
Practice Address - Phone:309-792-2426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.007833225X00000X
IA01771225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist