Provider Demographics
NPI:1740562602
Name:BROCK, LAVONNE ELISE (COTA/L)
Entity type:Individual
Prefix:MISS
First Name:LAVONNE
Middle Name:ELISE
Last Name:BROCK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3206 WOODWORT H PL.
Mailing Address - Street 2:
Mailing Address - City:HAZELCREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429
Mailing Address - Country:US
Mailing Address - Phone:773-387-0513
Mailing Address - Fax:
Practice Address - Street 1:3206 WOODWORTH PL
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1542
Practice Address - Country:US
Practice Address - Phone:773-387-0513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057000445224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant