MEDICARE: MICHELLE BROOK MONDAY OT

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	3847	SC

General Provider Information

NPI Number	:	1578517744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE BROOK MONDAY OT

Provider Business Mailing Address
First Line	:	PO BOX 1844
Second Line	:
City	:	CLEMSON
State	:	SC
Zip	:	29633-1844
Country	:	US
Telephone Number	:	864-482-0064
Fax Number	:	864-482-0081

Provider Business Practice Location Address
First Line	:	210 VILLAGE CENTER BLVD
Second Line	:	SUITE 100
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-6706
Country	:	US
Telephone Number	:	843-491-4937
Fax Number	:	843-491-4938

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

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	08/26/2011

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