Provider Demographics
NPI:1982107009
Name:ANTONSON, BROOK (OTR/L)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:
Last Name:ANTONSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:BROOK
Other - Middle Name:
Other - Last Name:KRALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:04915 64TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-7323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:04915 64TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-7323
Practice Address - Country:US
Practice Address - Phone:269-929-5764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010018225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist