Provider Demographics
NPI:1093979452
Name:ASHBROOK, PHYLLIS ANN
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:ANN
Last Name:ASHBROOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19215 HIGHWAY 62
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47141-9632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 POTTERS LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-1017
Practice Address - Country:US
Practice Address - Phone:812-948-0808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001146A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant