Provider Demographics
NPI:1326770363
Name:FOLTZ, BROOKE (LMP)
Entity Type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:
Last Name:FOLTZ
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 LONDON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404-9738
Mailing Address - Country:US
Mailing Address - Phone:971-273-9432
Mailing Address - Fax:
Practice Address - Street 1:80 ACOMA BLVD S STE 104&106
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6925
Practice Address - Country:US
Practice Address - Phone:928-453-1055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-27870225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty