MEDICARE: BROOKE E WOODALL OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OT19515	FL

General Provider Information

NPI Number	:	1518441153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE E WOODALL OTR/L

Provider Business Mailing Address
First Line	:	1412 1ST ST N APT 109
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-7371
Country	:	US
Telephone Number	:	904-504-9747
Fax Number	:

Provider Business Practice Location Address
First Line	:	14785 OLD SAINT AUGUSTINE RD STE 100
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-7407
Country	:	US
Telephone Number	:	904-292-1808
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2018
Last Update Date	:	09/19/2018

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