Provider Demographics
NPI:1790354710
Name:BROOKS, KEVIN (PTA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BROOKS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9940 EDMONTON DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-6051
Mailing Address - Country:US
Mailing Address - Phone:915-926-6606
Mailing Address - Fax:
Practice Address - Street 1:4895 W WATERS AVE STE E
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-1316
Practice Address - Country:US
Practice Address - Phone:915-932-3315
Practice Address - Fax:813-935-9835
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA31090225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty