Provider Demographics
NPI:1851416556
Name:MANNEBACH, BROOKE LEESA (COTA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LEESA
Last Name:MANNEBACH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 N GRIMES ST
Mailing Address - Street 2:
Mailing Address - City:MCPHERSON
Mailing Address - State:KS
Mailing Address - Zip Code:67460-2822
Mailing Address - Country:US
Mailing Address - Phone:620-245-5550
Mailing Address - Fax:
Practice Address - Street 1:700 MONTEREY PL
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-2266
Practice Address - Country:US
Practice Address - Phone:620-664-6219
Practice Address - Fax:620-663-3133
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1800463224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant