Provider Demographics
NPI:1053864496
Name:BROOKS, CORRYN A (ATC)
Entity Type:Individual
Prefix:MRS
First Name:CORRYN
Middle Name:A
Last Name:BROOKS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:CORRYN
Other - Middle Name:A
Other - Last Name:POBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:43 LAKE METONGA TRL
Mailing Address - Street 2:
Mailing Address - City:GRANT PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60940-9778
Mailing Address - Country:US
Mailing Address - Phone:815-508-3053
Mailing Address - Fax:
Practice Address - Street 1:43 LAKE METONGA TRL
Practice Address - Street 2:
Practice Address - City:GRANT PARK
Practice Address - State:IL
Practice Address - Zip Code:60940-9778
Practice Address - Country:US
Practice Address - Phone:815-508-3053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002662A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer