Provider Demographics
NPI:1619087020
Name:BROOKS, DOUGLAS
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:BROOKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WINSTON CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MOSSYROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98564-9648
Mailing Address - Country:US
Mailing Address - Phone:360-985-0664
Mailing Address - Fax:
Practice Address - Street 1:145 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3037
Practice Address - Country:US
Practice Address - Phone:360-748-1580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPTAOtherLICENSE #