Provider Demographics
NPI:1689153728
Name:TICE, BROOKE ELIZABETH
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELIZABETH
Last Name:TICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 N LICKERT HARDER RD
Mailing Address - Street 2:
Mailing Address - City:GRAYTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43432-9721
Mailing Address - Country:US
Mailing Address - Phone:419-262-1779
Mailing Address - Fax:
Practice Address - Street 1:2701 CHESTNUT STATION CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6395
Practice Address - Country:US
Practice Address - Phone:800-335-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA011736225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant