Provider Demographics
NPI:1144349135
Name:BRAINARD, CORY FURY (OT)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:FURY
Last Name:BRAINARD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CORY
Other - Middle Name:
Other - Last Name:FURY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OT
Mailing Address - Street 1:15465 OAK LANE SUITE 100 C
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2663
Mailing Address - Country:US
Mailing Address - Phone:504-615-2493
Mailing Address - Fax:228-265-8323
Practice Address - Street 1:15465 OAK LANE SUITE 100 C
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2663
Practice Address - Country:US
Practice Address - Phone:504-615-2493
Practice Address - Fax:228-265-8323
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ10511225X00000X
MSOT-1903225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1068802Medicaid