Provider Demographics
NPI:1174909386
Name:BROCKWAY, MICHELE (MS, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:
Last Name:BROCKWAY
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2836 SHEEPHEAD CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-2441
Mailing Address - Country:US
Mailing Address - Phone:843-697-6874
Mailing Address - Fax:
Practice Address - Street 1:2836 SHEEPHEAD CT
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-2441
Practice Address - Country:US
Practice Address - Phone:843-697-6874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 8068225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT 8068OtherOT LICENSE