Provider Demographics
NPI:1588971360
Name:VAN DECKER, BRENDA MITCHELL (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:MITCHELL
Last Name:VAN DECKER
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 1:167 LEACH HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:CASCO
Mailing Address - State:ME
Mailing Address - Zip Code:04015
Mailing Address - Country:US
Mailing Address - Phone:207-627-7207
Mailing Address - Fax:
Practice Address - Street 1:60 COURT STREET
Practice Address - Street 2:AUBURN SCHOOL DEPARTMENT
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04212-0800
Practice Address - Country:US
Practice Address - Phone:207-333-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEO1613A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant