Provider Demographics
NPI:1033680590
Name:WHITE, BROOKS L (PTA)
Entity Type:Individual
Prefix:
First Name:BROOKS
Middle Name:L
Last Name:WHITE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 N STEELE BLVD STE 80
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5394
Mailing Address - Country:US
Mailing Address - Phone:479-422-9404
Mailing Address - Fax:479-439-4641
Practice Address - Street 1:4155 N STEELE BLVD STE 80
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5394
Practice Address - Country:US
Practice Address - Phone:479-422-9404
Practice Address - Fax:479-439-4641
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA3945225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant