Healthcare Provider Details

I. General information

NPI: 1518441153
Provider Name (Legal Business Name): BROOKE E WOODALL OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14785 OLD SAINT AUGUSTINE RD STE 100
JACKSONVILLE FL
32258-7407
US

IV. Provider business mailing address

1412 1ST ST N APT 109
JACKSONVILLE BEACH FL
32250-7371
US

V. Phone/Fax

Practice location:
  • Phone: 904-292-1808
  • Fax:
Mailing address:
  • Phone: 904-504-9747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT19515
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: