Provider Demographics
NPI:1891032488
Name:BROWN, MONIQUE SHAWNTAE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:SHAWNTAE
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 WOODGATE TRL
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-2989
Mailing Address - Country:US
Mailing Address - Phone:321-439-5481
Mailing Address - Fax:
Practice Address - Street 1:1525 S ALAFAYA TRL STE 101
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-8926
Practice Address - Country:US
Practice Address - Phone:407-277-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10815224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant