Provider Demographics
NPI:1699382127
Name:BROCKMEYER, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BROCKMEYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 TIMBERLODGE LNDG
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-4696
Mailing Address - Country:US
Mailing Address - Phone:314-308-1861
Mailing Address - Fax:
Practice Address - Street 1:600 BREEZE VIEW LN
Practice Address - Street 2:
Practice Address - City:WELDON SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:63304
Practice Address - Country:US
Practice Address - Phone:636-939-5223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011030614225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist