Provider Demographics
NPI:1629570312
Name:WILLIS, BROOKE LYNN (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:LYNN
Last Name:WILLIS
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 1:3928 NEW HAMPSHIRE AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-7917
Mailing Address - Country:US
Mailing Address - Phone:440-487-6160
Mailing Address - Fax:
Practice Address - Street 1:111 MICHIGAN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2916
Practice Address - Country:US
Practice Address - Phone:202-476-4265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOT010001312225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics