Provider Demographics
NPI:1780236141
Name:KIDD, BREELYN NOEL (COTA/L)
Entity type:Individual
Prefix:
First Name:BREELYN
Middle Name:NOEL
Last Name:KIDD
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MAXWELL AVE STE 312
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-2641
Mailing Address - Country:US
Mailing Address - Phone:864-229-7529
Mailing Address - Fax:864-229-7530
Practice Address - Street 1:104 MAXWELL AVE STE 312
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2641
Practice Address - Country:US
Practice Address - Phone:864-229-7529
Practice Address - Fax:864-229-7530
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4883224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant