Provider Demographics
NPI:1255712261
Name:MCINTOSH, BROOKE NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:NICOLE
Other - Last Name:JANICKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7505 N LOOP 1604 E STE 101
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-2604
Mailing Address - Country:US
Mailing Address - Phone:210-590-4000
Mailing Address - Fax:210-590-4585
Practice Address - Street 1:5917 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-5235
Practice Address - Country:US
Practice Address - Phone:210-253-3450
Practice Address - Fax:210-477-1037
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAF517OtherBLUE CROSS OF MARYALND
MD434MMedicare PIN