Provider Demographics
NPI:1093974412
Name:BROOKLANE THERAPY SERVICES
Entity Type:Organization
Organization Name:BROOKLANE THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:G
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:706-379-4068
Mailing Address - Street 1:6724 MORGAN CT
Mailing Address - Street 2:
Mailing Address - City:YOUNG HARRIS
Mailing Address - State:GA
Mailing Address - Zip Code:30582-2551
Mailing Address - Country:US
Mailing Address - Phone:706-379-4068
Mailing Address - Fax:706-379-0640
Practice Address - Street 1:6724 MORGAN CT
Practice Address - Street 2:
Practice Address - City:YOUNG HARRIS
Practice Address - State:GA
Practice Address - Zip Code:30582-2551
Practice Address - Country:US
Practice Address - Phone:706-379-4068
Practice Address - Fax:706-379-0640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC225XP0200225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212219Medicaid
NC7301999Medicaid