Provider Demographics
NPI:1215575469
Name:GEORGE, BROOKS AUTUMN (LMT)
Entity Type:Individual
Prefix:
First Name:BROOKS
Middle Name:AUTUMN
Last Name:GEORGE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:BROOKS
Other - Middle Name:AUTUMN
Other - Last Name:EBERLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19250 VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-1335
Mailing Address - Country:US
Mailing Address - Phone:435-531-8681
Mailing Address - Fax:
Practice Address - Street 1:3 MONROE PKWY STE U
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-8875
Practice Address - Country:US
Practice Address - Phone:503-387-3205
Practice Address - Fax:503-336-1001
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25365225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist