Provider Demographics
NPI:1265239701
Name:PERSONS, BROOKE (MS)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:PERSONS
Suffix:
Gender:
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 TROUT LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BOLTON LANDING
Mailing Address - State:NY
Mailing Address - Zip Code:12814-3009
Mailing Address - Country:US
Mailing Address - Phone:518-415-5436
Mailing Address - Fax:
Practice Address - Street 1:691 TROUT LAKE RD
Practice Address - Street 2:
Practice Address - City:BOLTON LANDING
Practice Address - State:NY
Practice Address - Zip Code:12814-3009
Practice Address - Country:US
Practice Address - Phone:518-415-5436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency