Provider Demographics
NPI:1215565445
Name:KELLER, BROOK (COTAL)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8371 FAIRLANE DR APT 5
Mailing Address - Street 2:
Mailing Address - City:BIRCH RUN
Mailing Address - State:MI
Mailing Address - Zip Code:48415-9774
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8371 FAIRLANE DR APT 5
Practice Address - Street 2:
Practice Address - City:BIRCH RUN
Practice Address - State:MI
Practice Address - Zip Code:48415-9774
Practice Address - Country:US
Practice Address - Phone:989-323-7489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
MI5202008485224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant