Basic Information
| Provider Information | |||||||||
| NPI: | 1518125350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RALEY | ||||||||
| FirstName: | BREENA | ||||||||
| MiddleName: | COFFIELD | ||||||||
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| Credential: | MHS - OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 207 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | GROVETOWN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308132520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063646172 | ||||||||
| FaxNumber: | 7062622893 | ||||||||
| Practice Location | |||||||||
| Address1: | 2315 CENTRAL AVE STE C | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309046246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063646172 | ||||||||
| FaxNumber: | 7062622893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2008 | ||||||||
| LastUpdateDate: | 05/29/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.