Provider Demographics
NPI:1770196123
Name:THOMAS, BROOKE ANN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:ANN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 NUTMEG LANE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046
Mailing Address - Country:US
Mailing Address - Phone:228-216-5998
Mailing Address - Fax:
Practice Address - Street 1:627 MIDDLETON RD STE 100
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-2000
Practice Address - Country:US
Practice Address - Phone:662-283-1260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3797225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist