Healthcare Provider Details

I. General information

NPI: 1528212107
Provider Name (Legal Business Name): LESLIE BROOKE BROCK MS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E KENTUCKY ST
LOUISVILLE KY
40203-2793
US

IV. Provider business mailing address

115 E KENTUCKY ST
LOUISVILLE KY
40203-2793
US

V. Phone/Fax

Practice location:
  • Phone: 502-371-9910
  • Fax: 502-515-3325
Mailing address:
  • Phone: 502-371-9910
  • Fax: 502-515-3325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT 13304
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number131957
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: