Provider Demographics
NPI:1417372608
Name:ANDERSON, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-2640
Mailing Address - Country:US
Mailing Address - Phone:541-520-9079
Mailing Address - Fax:
Practice Address - Street 1:1631 RIVER RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-2640
Practice Address - Country:US
Practice Address - Phone:541-520-9079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19454225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist