Provider Demographics
NPI:1154509271
Name:BROCKMAN, ANTOINETTE (OT)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24988
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0988
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:2200 NE NEFF RD
Practice Address - Street 2:SUITE 202
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4283
Practice Address - Country:US
Practice Address - Phone:541-388-7738
Practice Address - Fax:541-312-0121
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR908779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist