Provider Demographics
NPI:1417119504
Name:BISHOP, BROOKE HAYLEY (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:HAYLEY
Last Name:BISHOP
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 BERRY ST
Mailing Address - Street 2:
Mailing Address - City:DENNISON
Mailing Address - State:IL
Mailing Address - Zip Code:62423-2109
Mailing Address - Country:US
Mailing Address - Phone:217-463-2572
Mailing Address - Fax:217-465-6380
Practice Address - Street 1:400 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHRISMAN
Practice Address - State:IL
Practice Address - Zip Code:61924-1042
Practice Address - Country:US
Practice Address - Phone:217-269-2105
Practice Address - Fax:217-269-2108
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004229225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant