Provider Demographics
NPI:1235440553
Name:GARDNER, BROOKE M (PT, AT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:M
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PT, AT
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:M
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT,AT
Mailing Address - Street 1:421 CAMELOT DR
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-8335
Mailing Address - Country:US
Mailing Address - Phone:920-923-7940
Mailing Address - Fax:
Practice Address - Street 1:421 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-8335
Practice Address - Country:US
Practice Address - Phone:920-923-7940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2014-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11523-24225100000X
WI927-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer