Provider Demographics
NPI:1376109579
Name:LEONARD, BROOKE MARIE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:MARIE
Last Name:LEONARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:BACKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:963 HEATHER DR
Mailing Address - Street 2:
Mailing Address - City:PEOSTA
Mailing Address - State:IA
Mailing Address - Zip Code:52068-9452
Mailing Address - Country:US
Mailing Address - Phone:563-513-8819
Mailing Address - Fax:
Practice Address - Street 1:3375 LAKE RIDGE DR
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52003-7864
Practice Address - Country:US
Practice Address - Phone:563-207-8932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001418225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant