Provider Demographics
NPI:1063601862
Name:HENRY, BROOKE (PTA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:HENRY
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 1:18440 S PEEPLES VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PEEPLES VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86332-8630
Mailing Address - Country:US
Mailing Address - Phone:920-362-0121
Mailing Address - Fax:
Practice Address - Street 1:2919 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-2717
Practice Address - Country:US
Practice Address - Phone:520-326-2782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7775A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant