Provider Demographics
NPI:1154088383
Name:VENKITACHALAM, BROOKE SHEILA
Entity Type:Individual
Prefix:MISS
First Name:BROOKE
Middle Name:SHEILA
Last Name:VENKITACHALAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 W TOWNSEND RD
Mailing Address - Street 2:
Mailing Address - City:LUNENBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01462-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 MOUNT CARMEL AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-1908
Practice Address - Country:US
Practice Address - Phone:978-760-9107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer