Provider Demographics
NPI:1881876597
Name:BREACH, CAMILLA JEAN (OTR)
Entity type:Individual
Prefix:MS
First Name:CAMILLA
Middle Name:JEAN
Last Name:BREACH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:CAMILLA
Other - Middle Name:JEAN
Other - Last Name:TURNER BREACH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:131-34 133RD STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-3425
Mailing Address - Country:US
Mailing Address - Phone:718-659-4923
Mailing Address - Fax:
Practice Address - Street 1:333 AVENUE S
Practice Address - Street 2:VCP
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223
Practice Address - Country:US
Practice Address - Phone:718-376-8311
Practice Address - Fax:718-645-6454
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0115181225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist