Basic Information
| Provider Information | |||||||||
| NPI: | 1598044851 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRASEL | ||||||||
| FirstName: | JERRY | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 ENTERPRISE DR | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605238813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305751916 | ||||||||
| FaxNumber: | 6309285016 | ||||||||
| Practice Location | |||||||||
| Address1: | 5510 W LINCOLN HWY | ||||||||
| Address2: | (US ROUTE 30) | ||||||||
| City: | SCHERERVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463751020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198651436 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2011 | ||||||||
| LastUpdateDate: | 04/20/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31001355A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 056-002245 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.