Provider Demographics
NPI:1841718871
Name:MARTIN, BROOKE ELLYN (PT, DPT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELLYN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PT, DPT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 STEEPLECHASE LN
Mailing Address - Street 2:
Mailing Address - City:BOONES MILL
Mailing Address - State:VA
Mailing Address - Zip Code:24065
Mailing Address - Country:US
Mailing Address - Phone:540-266-4037
Mailing Address - Fax:
Practice Address - Street 1:13307 BOOKER T WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:HARDY
Practice Address - State:VA
Practice Address - Zip Code:24101-3945
Practice Address - Country:US
Practice Address - Phone:540-721-4199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214275225100000X
2255A2300X, 390200000X
VA01260029932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program