Provider Demographics
NPI:1376557827
Name:BREW, AILEEN O'CONNELL (DPT)
Entity type:Individual
Prefix:
First Name:AILEEN
Middle Name:O'CONNELL
Last Name:BREW
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 WEST SUNSET DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501
Mailing Address - Country:US
Mailing Address - Phone:307-856-7021
Mailing Address - Fax:307-856-5541
Practice Address - Street 1:8168 HWY 789
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520
Practice Address - Country:US
Practice Address - Phone:307-332-5240
Practice Address - Fax:307-332-5241
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT1001225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY312064OtherBLUE CROSS BLUE SHIELD
WY312064OtherBLUE CROSS BLUE SHIELD
WYW9445Medicare PIN