Provider Demographics
NPI:1700605789
Name:SMITH, BROOKE A (MT)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 VILLA RDG
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5881
Mailing Address - Country:US
Mailing Address - Phone:770-843-8600
Mailing Address - Fax:
Practice Address - Street 1:2006 VILLA RDG
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-5881
Practice Address - Country:US
Practice Address - Phone:770-843-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR9225225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist