Provider Demographics
NPI:1902466857
Name:RAINS, BRENTON (COTA/L)
Entity Type:Individual
Prefix:
First Name:BRENTON
Middle Name:
Last Name:RAINS
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 HYLAND RD APT 5
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62233-1245
Mailing Address - Country:US
Mailing Address - Phone:618-615-8241
Mailing Address - Fax:
Practice Address - Street 1:13138 IL-13
Practice Address - Street 2:
Practice Address - City:COULTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62237
Practice Address - Country:US
Practice Address - Phone:618-758-2256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.005153224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant