Provider Demographics
NPI:1679555700
Name:BROOKS, SHANA (MPT)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:
Other - Last Name:SLEGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:1239 NE MEDICAL CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7359
Mailing Address - Country:US
Mailing Address - Phone:541-385-3344
Mailing Address - Fax:541-312-5256
Practice Address - Street 1:1239 NE MEDICAL CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7359
Practice Address - Country:US
Practice Address - Phone:541-385-3344
Practice Address - Fax:541-312-5256
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182550Medicaid
ORH254805OtherPACIFIC SOURCE
OR804449004OtherBLUE CROSS/BLUE SHIELD
331581OtherPROVIDENCE
5512826OtherFIRST HEALTH
ORR142281Medicare UPIN