Provider Demographics
NPI:1700903457
Name:BREECH, BEVERLY ANN (COTA)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANN
Last Name:BREECH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 HONEYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-8869
Mailing Address - Country:US
Mailing Address - Phone:540-989-7031
Mailing Address - Fax:
Practice Address - Street 1:2001 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153
Practice Address - Country:US
Practice Address - Phone:540-378-4120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA985315224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant