Provider Demographics
NPI:1023540531
Name:BRENTOM, LLC,
Entity Type:Organization
Organization Name:BRENTOM, LLC,
Other - Org Name:SHARKKS THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:MAURICE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OTR/L
Authorized Official - Phone:602-430-8665
Mailing Address - Street 1:20783 N 83RD AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-7430
Mailing Address - Country:US
Mailing Address - Phone:623-444-8880
Mailing Address - Fax:623-444-9282
Practice Address - Street 1:20783 N 83RD AVE STE 103
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-7430
Practice Address - Country:US
Practice Address - Phone:623-444-8880
Practice Address - Fax:623-444-9282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-03
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2491225X00000X, 225XH1200X, 225XM0800X, 225XP0019X, 225XP0200X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental HealthGroup - Multi-Specialty
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ501032Medicaid
AZ501032Medicaid