Individual
BROOK TRAVIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
206 MARYLAND AVE, MCCOMB, MS 39648
(601) 250-4815
Mailing address
570 S DEERFIELD DR, CANTON, MS 39046
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
TA2157
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
TA2157
COTA
MS
Enumeration date
09/10/2007
Last updated
09/10/2007
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