Provider Demographics
NPI:1114476686
Name:LABOSSIERE, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:LABOSSIERE
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 1:12110 BUSINESS BLVD
Mailing Address - Street 2:STE 6 PMB 413
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7741
Mailing Address - Country:US
Mailing Address - Phone:907-317-9349
Mailing Address - Fax:
Practice Address - Street 1:337 COTUIT RD
Practice Address - Street 2:
Practice Address - City:FORESTDALE
Practice Address - State:MA
Practice Address - Zip Code:02644
Practice Address - Country:US
Practice Address - Phone:508-833-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK115142225X00000X
MA12519225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist