Provider Demographics
NPI:1700282738
Name:STEPIEN, BROOKE LEIGH
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:LEIGH
Last Name:STEPIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 SE 47TH ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-5591
Mailing Address - Country:US
Mailing Address - Phone:239-674-9374
Mailing Address - Fax:239-491-3057
Practice Address - Street 1:904 LEE BLVD
Practice Address - Street 2:UNIT 106
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-4953
Practice Address - Country:US
Practice Address - Phone:239-674-9374
Practice Address - Fax:239-491-3057
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA14112224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006236000Medicaid