Provider Demographics
NPI:1164532198
Name:KALISIAK, BROOKE MARIE (PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:MARIE
Last Name:KALISIAK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2961 DOUGHERTY FERRY RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-3374
Mailing Address - Country:US
Mailing Address - Phone:636-225-3649
Mailing Address - Fax:888-494-7074
Practice Address - Street 1:2961 DOUGHERTY FERRY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3374
Practice Address - Country:US
Practice Address - Phone:636-225-3649
Practice Address - Fax:888-494-7074
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO70013529225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO990101509Medicare ID - Type Unspecified