Provider Demographics
NPI:1790509222
Name:BROWN, MONIQUE (PTA)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3538 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2246
Mailing Address - Country:US
Mailing Address - Phone:219-316-7470
Mailing Address - Fax:
Practice Address - Street 1:3538 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2246
Practice Address - Country:US
Practice Address - Phone:219-316-7470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06006909A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant