Provider Demographics
NPI:1003694134
Name:EDDE, BROOKE ALLISON (LMT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALLISON
Last Name:EDDE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4578 S WOODDUCK LN
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4117
Mailing Address - Country:US
Mailing Address - Phone:180-164-4910
Mailing Address - Fax:
Practice Address - Street 1:4885 S 900 E STE 201A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-3907
Practice Address - Country:US
Practice Address - Phone:801-644-9104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8986754-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty