Provider Demographics
NPI:1003852724
Name:HUETTNER, BROOKE AMBER (DC)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:AMBER
Last Name:HUETTNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:AMBER
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 W WISCONSIN ST
Mailing Address - Street 2:STE 4
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-2492
Mailing Address - Country:US
Mailing Address - Phone:608-269-4511
Mailing Address - Fax:608-269-8511
Practice Address - Street 1:415 W WISCONSIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-2492
Practice Address - Country:US
Practice Address - Phone:608-269-4511
Practice Address - Fax:608-269-8511
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4156-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38964000Medicaid
WI38984600OtherMEDICAID GROUP
391794159330OtherANTHEMBCBS
WI38984600OtherMEDICAID GROUP
391794159330OtherANTHEMBCBS