Provider Demographics
NPI:1790174597
Name:MANESS, BROOKE MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:MARIE
Last Name:MANESS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:MARIE
Other - Last Name:BUNDRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:100 NETHERLAND LANE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660
Mailing Address - Country:US
Mailing Address - Phone:423-245-0360
Mailing Address - Fax:
Practice Address - Street 1:1300 BLOOMINGDALE PIKE
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-2685
Practice Address - Country:US
Practice Address - Phone:865-531-2204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3983225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist