Provider Demographics
NPI:1659181469
Name:PETKOVICH, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:PETKOVICH
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 1:5608 ERLANGER RD
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-1564
Mailing Address - Country:US
Mailing Address - Phone:504-615-2133
Mailing Address - Fax:
Practice Address - Street 1:8501 WILSHIRE BLVD STE 336
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3134
Practice Address - Country:US
Practice Address - Phone:424-239-7817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-13
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11483225100000X
CA307551225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist