Provider Demographics
NPI:1073729752
Name:BROCKMEYER, BRENDA SUE (COTA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:SUE
Last Name:BROCKMEYER
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 1:5137 GLENN VALLEY DR APT 3B
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-7303
Mailing Address - Country:US
Mailing Address - Phone:269-290-5017
Mailing Address - Fax:
Practice Address - Street 1:3505 LAKE LYNDA DR
Practice Address - Street 2:SUITE 207
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8324
Practice Address - Country:US
Practice Address - Phone:407-249-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC00001236224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant