Provider Demographics
NPI:1275216228
Name:WELLS, BROOKE ALISE (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:ALISE
Last Name:WELLS
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 DEER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-5612
Mailing Address - Country:US
Mailing Address - Phone:601-249-7002
Mailing Address - Fax:
Practice Address - Street 1:4109 HIGHWAY 98 W
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:MS
Practice Address - Zip Code:39666-9132
Practice Address - Country:US
Practice Address - Phone:601-276-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4053225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist