Provider Demographics
NPI:1710696679
Name:WIGEN, BROOKE (OTD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:WIGEN
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MN
Mailing Address - Zip Code:56143-1806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1819 23RD ST
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-7096
Practice Address - Country:US
Practice Address - Phone:712-336-3553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105713225X00000X
IA092475225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist