Provider Demographics
NPI:1396133377
Name:BOENTE, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:BOENTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 HUNTLEIGH DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-6818
Mailing Address - Country:US
Mailing Address - Phone:217-556-9656
Mailing Address - Fax:
Practice Address - Street 1:1200 HOMELIFE PLZ
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2596
Practice Address - Country:US
Practice Address - Phone:217-556-9656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014035895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist