Provider Demographics
NPI:1275283970
Name:ROGERS, BROOKE TIARA (LMT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:TIARA
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 S FEDERAL WAY STE E
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-5925
Mailing Address - Country:US
Mailing Address - Phone:208-703-3899
Mailing Address - Fax:
Practice Address - Street 1:305 S FEDERAL WAY STE E
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-5925
Practice Address - Country:US
Practice Address - Phone:208-703-3899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-1885225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist