Provider Demographics
NPI:1154052652
Name:WOOTEN, STEVE BRENT II
Entity Type:Individual
Prefix:
First Name:STEVE
Middle Name:BRENT
Last Name:WOOTEN
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2269 WEKIVA LN
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-7476
Mailing Address - Country:US
Mailing Address - Phone:321-292-4578
Mailing Address - Fax:
Practice Address - Street 1:2269 WEKIVA LN
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-7476
Practice Address - Country:US
Practice Address - Phone:321-292-4578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA85306225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty