Provider Demographics
NPI:1568837342
Name:BROOKS, MOLLY (LMT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BROOKS
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 1:3705 ARCTIC BLVD
Mailing Address - Street 2:617
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-5774
Mailing Address - Country:US
Mailing Address - Phone:907-227-6420
Mailing Address - Fax:
Practice Address - Street 1:3800 LAKE OTIS PKWY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5209
Practice Address - Country:US
Practice Address - Phone:907-227-6420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-05
Last Update Date:2015-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0016220225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0016220OtherSTATE OF COLORADO