Provider Demographics
NPI:1124237128
Name:KANAVEL, BROOKE (COTAL)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:
Last Name:KANAVEL
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4429 283RD ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43611-1865
Mailing Address - Country:US
Mailing Address - Phone:419-726-5241
Mailing Address - Fax:
Practice Address - Street 1:7120 PORT SYLVANIA DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1158
Practice Address - Country:US
Practice Address - Phone:419-841-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA-02619224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant