Provider Demographics
NPI:1780283507
Name:FISHEL, BROOKE NICOLE (PTA/L)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:FISHEL
Suffix:
Gender:F
Credentials:PTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 N EAST ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:IL
Mailing Address - Zip Code:61748-9434
Mailing Address - Country:US
Mailing Address - Phone:309-287-3180
Mailing Address - Fax:309-454-4594
Practice Address - Street 1:203 N EAST ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:IL
Practice Address - Zip Code:61748-9434
Practice Address - Country:US
Practice Address - Phone:309-287-3180
Practice Address - Fax:309-454-4594
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005453225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant