=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184445561
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAKENZIE BREKEN ZOOK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2024
-----------------------------------------------------
Last Update Date | 10/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23537 TELEGRAPH RD
-----------------------------------------------------
City | BROWNSTOWN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48134-9330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-278-4601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4499 W PITCH PINE LN APT 1D
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-4916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-680-5996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------