Provider Demographics
NPI:1366194391
Name:HARRIS, BROOKE NICOLE (COTA/L)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:NICOLE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2672 W PERCH RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:VA
Mailing Address - Zip Code:24574-2993
Mailing Address - Country:US
Mailing Address - Phone:434-401-5960
Mailing Address - Fax:
Practice Address - Street 1:189 MONICA BLVD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2213
Practice Address - Country:US
Practice Address - Phone:434-847-2860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131001378224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty