Provider Demographics
NPI:1598057739
Name:BROOKS, MARY ELIZABETH (PTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:BROOKS
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 1:4922 W SALT RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SHEPHERD
Mailing Address - State:MI
Mailing Address - Zip Code:48883-8626
Mailing Address - Country:US
Mailing Address - Phone:989-773-2029
Mailing Address - Fax:
Practice Address - Street 1:3240 CHRISTY WAY S
Practice Address - Street 2:SUITE 3
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-2215
Practice Address - Country:US
Practice Address - Phone:989-401-1570
Practice Address - Fax:989-401-1571
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002397225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant