Provider Demographics
NPI:1619449832
Name:LEGATE, BROOKE (PTA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:LEGATE
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 1:117 HARMONY XING STE 4
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-9548
Mailing Address - Country:US
Mailing Address - Phone:706-454-1811
Mailing Address - Fax:
Practice Address - Street 1:117 HARMONY XING STE 4
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-9548
Practice Address - Country:US
Practice Address - Phone:706-454-1811
Practice Address - Fax:706-454-1812
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004042225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant