Provider Demographics
NPI:1215489364
Name:WHARTON, BROOKE MARIE (COTA/L)
Entity type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:MARIE
Last Name:WHARTON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 N BRENTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-8536
Mailing Address - Country:US
Mailing Address - Phone:352-746-6600
Mailing Address - Fax:
Practice Address - Street 1:2333 N BRENTWOOD CIR
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-8536
Practice Address - Country:US
Practice Address - Phone:352-746-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 15490224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant