Provider Demographics
NPI:1639850795
Name:BROOKS, MICAH MAELYNN (PTA)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:MAELYNN
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 1:6106 DEAN RD
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:AR
Mailing Address - Zip Code:72921-8140
Mailing Address - Country:US
Mailing Address - Phone:479-670-0533
Mailing Address - Fax:
Practice Address - Street 1:2611 E HERITAGE PKWY STE 3
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-6018
Practice Address - Country:US
Practice Address - Phone:479-334-0014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA4872225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant