Provider Demographics
NPI:1568729341
Name:BRADDOCK, BROOKE TOOLEY (OT, MOT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:TOOLEY
Last Name:BRADDOCK
Suffix:
Gender:F
Credentials:OT, MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9101 BURNET RD STE 103
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5260
Mailing Address - Country:US
Mailing Address - Phone:512-248-2422
Mailing Address - Fax:512-248-2354
Practice Address - Street 1:9101 BURNET RD STE 103
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5260
Practice Address - Country:US
Practice Address - Phone:512-248-2422
Practice Address - Fax:512-248-2354
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114627225X00000X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX342765001Medicaid