Provider Demographics
NPI:1841963949
Name:CAMPBELL, BROOKLYN ELIZABETH DARE (PTA)
Entity type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:ELIZABETH DARE
Last Name:CAMPBELL
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 1:20 ROLLING MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24450-7501
Mailing Address - Country:US
Mailing Address - Phone:540-383-9633
Mailing Address - Fax:
Practice Address - Street 1:160 KENDAL DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-1786
Practice Address - Country:US
Practice Address - Phone:540-463-1910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605741225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant