=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700312014
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOK SPENNER MS OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2017
-----------------------------------------------------
Last Update Date | 05/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 HARTFORD ST
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47904-2134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-423-6885
-----------------------------------------------------
Fax | 765-423-6099
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8486 S 950 E
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47905-9312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-414-3764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 31003585A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------