Provider Demographics
NPI:1760104525
Name:DETRICK, BROOK COLBURN (LMT, CMLDT)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:COLBURN
Last Name:DETRICK
Suffix:
Gender:F
Credentials:LMT, CMLDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 SCRAPER ST
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-2509
Mailing Address - Country:US
Mailing Address - Phone:918-706-1302
Mailing Address - Fax:
Practice Address - Street 1:1501 N FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3179
Practice Address - Country:US
Practice Address - Phone:918-706-1302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK157786225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist