Provider Demographics
NPI:1619661212
Name:BROOKS, MEGAN (DO)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 S WASHINGTON AVE # A
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-1648
Mailing Address - Country:US
Mailing Address - Phone:415-244-8570
Mailing Address - Fax:
Practice Address - Street 1:4660 S HAGADORN RD STE 500
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6804
Practice Address - Country:US
Practice Address - Phone:517-432-6144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501016061225700000X
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist