Basic Information
| Provider Information | |||||||||
| NPI: | 1083277222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALANISH | ||||||||
| FirstName: | BREANNA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | COTA/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 20909 PLEASANT VIEW LN SW | ||||||||
| Address2: | |||||||||
| City: | RAWLINGS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215572508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013570376 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1543 COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | FAIRMONT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265541306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043632273 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2019 | ||||||||
| LastUpdateDate: | 04/14/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | C2264 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.