Healthcare Provider Details

I. General information

NPI: 1568811982
Provider Name (Legal Business Name): BROOKE WASHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30325 FINE DR
LACLEDE MO
64651-8102
US

IV. Provider business mailing address

30325 FINE DR
LACLEDE MO
64651-8102
US

V. Phone/Fax

Practice location:
  • Phone: 660-734-8196
  • Fax:
Mailing address:
  • Phone: 660-734-8196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2015018447
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number213545
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number81269
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number986
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: