Provider Demographics
NPI:1902121353
Name:BRIGANCE, SELINA RENEE (COTA)
Entity Type:Individual
Prefix:
First Name:SELINA
Middle Name:RENEE
Last Name:BRIGANCE
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 1:1560 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:BROWDER
Mailing Address - State:KY
Mailing Address - Zip Code:42326-2559
Mailing Address - Country:US
Mailing Address - Phone:270-543-6415
Mailing Address - Fax:
Practice Address - Street 1:1561 NEWTON AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3238
Practice Address - Country:US
Practice Address - Phone:270-842-1611
Practice Address - Fax:270-842-3858
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA3828224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant