Provider Demographics
NPI:1477438422
Name:STEVENS, BROOKE LAUREN (COTA/L)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:LAUREN
Last Name:STEVENS
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 1:5103 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-5425
Mailing Address - Country:US
Mailing Address - Phone:386-285-4143
Mailing Address - Fax:
Practice Address - Street 1:2669 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8217
Practice Address - Country:US
Practice Address - Phone:321-972-8326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-08
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20076208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics