Provider Demographics
NPI:1821695172
Name:MILLER, BROOKE MARIE (MA, R-DMT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:MA, R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3202 N 52ND ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-3242
Mailing Address - Country:US
Mailing Address - Phone:715-892-2852
Mailing Address - Fax:
Practice Address - Street 1:10150 W NATIONAL AVE STE 390
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-2145
Practice Address - Country:US
Practice Address - Phone:414-545-4430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WI2399225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health