Individual
MISS LAVONNE ELISE BROCK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
COTA/L
Contact information
Practice address
3206 WOODWORTH PL, HAZEL CREST, IL 60429-1542
(773) 387-0513
Mailing address
3206 WOODWORT H PL., HAZELCREST, IL 60429
(773) 387-0513
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
057000445
IL
Other
Enumeration date
09/15/2011
Last updated
09/15/2011
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