Provider Demographics
NPI:1265869184
Name:CHUA MCBROOM, PHILUSA (OTDR/L)
Entity type:Individual
Prefix:
First Name:PHILUSA
Middle Name:
Last Name:CHUA MCBROOM
Suffix:
Gender:F
Credentials:OTDR/L
Other - Prefix:
Other - First Name:PHILUSA
Other - Middle Name:
Other - Last Name:CHUA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100B LINDSEY LANE
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548
Mailing Address - Country:US
Mailing Address - Phone:912-510-6104
Mailing Address - Fax:912-882-6137
Practice Address - Street 1:100B LINDSEY LANE
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548
Practice Address - Country:US
Practice Address - Phone:912-510-6104
Practice Address - Fax:912-882-6137
Is Sole Proprietor?:No
Enumeration Date:2013-10-09
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15996225X00000X
GAOT005932225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist