MEDICARE: MS. BROOKE VANDOREN

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	2010012599	MO

General Provider Information

NPI Number	:	1528369402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BROOKE VANDOREN

Provider Business Mailing Address
First Line	:	1483 DARTMOUTH DR
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-3662
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1483 DARTMOUTH DR
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-3662
Country	:	US
Telephone Number	:	618-210-2885
Fax Number	:

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

Provider Enumeration Date	:	11/09/2010
Last Update Date	:	11/09/2010

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