Provider Demographics
NPI:1245409291
Name:STEVENS, BROOK ELLEN
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:ELLEN
Last Name:STEVENS
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 1:895 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1648
Mailing Address - Country:US
Mailing Address - Phone:321-768-7670
Mailing Address - Fax:321-768-7633
Practice Address - Street 1:895 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1648
Practice Address - Country:US
Practice Address - Phone:321-768-7670
Practice Address - Fax:321-768-7633
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications
No171WH0202XOther Service ProvidersContractorHome Modifications