Active NPI
Marie Stella Bravante Image, OTR L
- Occupational Therapist
- Roswell, NM
National Provider Identifier
1336291855
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Occupational Therapist
- License
- 2153
- Practice address
- 300 N Kentucky Ave
Roswell, NM 88201-4636 - Phone
- (505) 627-0192
- Fax
- (505) 627-2544
- NPI assigned
- Jan 17, 2007
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Occupational Therapist | 225X00000X | 2153 | NM | Primary |
Addresses
Primary practice location
300 N Kentucky Ave
Roswell, NM 88201-4636
Mailing address
700 N Missouri Ave Apt 38
Roswell, NM 88201-4861
Phone (505) 627-0192
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 78300070 | Medicaid | NM |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2153 | NM | MD | Chiropractor |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Roswell Independent School District | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Local Education Agency (LEA)
- Roswell, NM
- NPI 1669522231
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1168992000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183939200000",
"number": "1336291855",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "700 N MISSOURI AVE APT 38",
"city": "ROSWELL",
"state": "NM",
"postal_code": "882014861",
"telephone_number": "505-627-0192"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "300 N KENTUCKY AVE",
"city": "ROSWELL",
"state": "NM",
"postal_code": "882014636",
"telephone_number": "505-627-0192",
"fax_number": "505-627-2544"
}
],
"practiceLocations": [],
"basic": {
"last_name": "IMAGE",
"first_name": "MARIE STELLA",
"middle_name": "BRAVANTE",
"name_prefix": "Ms.",
"credential": "OTR L",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2007-01-17",
"last_updated": "2007-07-09",
"status": "A"
},
"taxonomies": [
{
"code": "225X00000X",
"taxonomy_group": "",
"desc": "Occupational Therapist",
"state": "NM",
"license": "2153",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "78300070",
"state": "NM"
}
],
"endpoints": [],
"other_names": []
}Other providers in Roswell, NM
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.