Provider Demographics
NPI:1487118246
Name:BREIDENBACH, ROXANN (COTA)
Entity type:Individual
Prefix:
First Name:ROXANN
Middle Name:
Last Name:BREIDENBACH
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 1:402 SALINITY DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42345-1742
Mailing Address - Country:US
Mailing Address - Phone:270-619-1405
Mailing Address - Fax:
Practice Address - Street 1:515 GREENE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-1409
Practice Address - Country:US
Practice Address - Phone:270-338-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210923224Z00000X
KY262620224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant