Provider Demographics
NPI:1144578295
Name:BROWN, BROOKE RENEE (PTA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:RENEE
Last Name:BROWN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N WALL ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2901
Mailing Address - Country:US
Mailing Address - Phone:815-935-7514
Mailing Address - Fax:815-935-7069
Practice Address - Street 1:105 S FIRST ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:IL
Practice Address - Zip Code:60481-8973
Practice Address - Country:US
Practice Address - Phone:815-476-5210
Practice Address - Fax:815-476-1080
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160003870225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant