Basic Information
| Provider Information | |||||||||
| NPI: | 1407902281 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRICKENDEN | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.A., OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2736 HOLLYWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330204808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546031881 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2736 HOLLYWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330204808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546031881 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 10/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | OT8580 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 884789400 | 05 | FL | MEDICAID |