Provider Demographics
NPI:1063685915
Name:CONDRA, BROOKE (COTA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:CONDRA
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2071 N STATE ROAD 37
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:IN
Mailing Address - Zip Code:47454-9704
Mailing Address - Country:US
Mailing Address - Phone:812-849-2221
Mailing Address - Fax:
Practice Address - Street 1:24 TEKE BURTON DR
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:IN
Practice Address - Zip Code:47446-7360
Practice Address - Country:US
Practice Address - Phone:812-849-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001598A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant