Provider Demographics
NPI:1922853555
Name:WHITE, BROOKE (PTA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2179
Mailing Address - Country:US
Mailing Address - Phone:574-514-9296
Mailing Address - Fax:
Practice Address - Street 1:1129 PARKWAY AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-1395
Practice Address - Country:US
Practice Address - Phone:574-514-9296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004379A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant