Provider Demographics
NPI:1417916842
Name:ROUSSEAU, BROOKE C (PT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:C
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 SANDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-6641
Mailing Address - Country:US
Mailing Address - Phone:949-872-1507
Mailing Address - Fax:
Practice Address - Street 1:1361F W. WADE HAMPTON BLVD
Practice Address - Street 2:PMB 207
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650
Practice Address - Country:US
Practice Address - Phone:864-801-8706
Practice Address - Fax:864-848-7203
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211630Medicaid
NC7211630Medicaid
NC2506287Medicare PIN