Provider Demographics
NPI:1396221065
Name:SEROTKIN, BROOKE (LMT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:SEROTKIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1458 W TRUMBULL RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49664-9642
Mailing Address - Country:US
Mailing Address - Phone:314-686-7249
Mailing Address - Fax:
Practice Address - Street 1:13561 S WEST BAY SHORE DR STE 204
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-6292
Practice Address - Country:US
Practice Address - Phone:313-686-7249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501010096225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty