Individual
BROOKE SOUTHIVONG
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
884 BEAL BROOK PASS, FORT WAYNE, IN 46814-8236
(260) 479-0828
Mailing address
884 BEAL BROOK PASS, FORT WAYNE, IN 46814-8236
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
32002424A
IN
Other
Enumeration date
09/10/2013
Last updated
02/20/2014
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