Provider Demographics
NPI:1790815587
Name:MILLS, BROOKE (MPT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:MILLS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:JUNKIN-MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:PO BOX 1343
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48347-1343
Mailing Address - Country:US
Mailing Address - Phone:410-796-8499
Mailing Address - Fax:
Practice Address - Street 1:9256 BENDIX RD
Practice Address - Street 2:STE 105,106
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-1840
Practice Address - Country:US
Practice Address - Phone:410-796-8499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-011481-L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019331860001Medicaid