Provider Demographics
NPI:1427574144
Name:GRANGER, BROOKE AUBREY (COTA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:AUBREY
Last Name:GRANGER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3731 BAUGHMAN CUTOFF RD
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-7701
Mailing Address - Country:US
Mailing Address - Phone:816-217-0041
Mailing Address - Fax:
Practice Address - Street 1:1 PARK DR STE A
Practice Address - Street 2:
Practice Address - City:HOLIDAY ISLAND
Practice Address - State:AR
Practice Address - Zip Code:72631-9405
Practice Address - Country:US
Practice Address - Phone:479-363-6422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant