Provider Demographics
NPI:1710440037
Name:WILSON, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:WILSON
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 1:9372 E PICKWICK CIR BLDG 14
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9372 E PICKWICK CIR BLDG 14
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3854
Practice Address - Country:US
Practice Address - Phone:248-800-6622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501006614225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty