Provider Demographics
NPI:1508298084
Name:TANK, BROOKE (COTA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:TANK
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 1:301 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLACK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54106-9518
Mailing Address - Country:US
Mailing Address - Phone:920-419-1095
Mailing Address - Fax:
Practice Address - Street 1:325 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-1325
Practice Address - Country:US
Practice Address - Phone:920-731-7310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4973-27224Z00000X
WI302705224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant