Provider Demographics
NPI:1780936245
Name:WELCH, BRIENNE (COTA)
Entity type:Individual
Prefix:
First Name:BRIENNE
Middle Name:
Last Name:WELCH
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 1:186 W RHUDES CREEK RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:KY
Mailing Address - Zip Code:42740-8327
Mailing Address - Country:US
Mailing Address - Phone:270-307-8153
Mailing Address - Fax:
Practice Address - Street 1:27240 HAGGERTY RD
Practice Address - Street 2:SUITE E 15
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-5716
Practice Address - Country:US
Practice Address - Phone:248-488-0350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY289570224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant