Provider Demographics
NPI:1174071930
Name:GERVACIO, BREANA
Entity type:Individual
Prefix:
First Name:BREANA
Middle Name:
Last Name:GERVACIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N 85TH ST UNIT 127
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-3818
Mailing Address - Country:US
Mailing Address - Phone:956-337-6606
Mailing Address - Fax:
Practice Address - Street 1:2335 E SAUNDERS ST # 3
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-5434
Practice Address - Country:US
Practice Address - Phone:956-717-0441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61513765225XP0200X
TX117892225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics