Provider Demographics
NPI:1366296675
Name:KEMMERER, BROOKE MICHELLE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:MICHELLE
Last Name:KEMMERER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 N 2ND ST APT B4
Mailing Address - Street 2:
Mailing Address - City:SOUDERTON
Mailing Address - State:PA
Mailing Address - Zip Code:18964-1110
Mailing Address - Country:US
Mailing Address - Phone:717-283-7774
Mailing Address - Fax:
Practice Address - Street 1:130 N 2ND ST APT B4
Practice Address - Street 2:
Practice Address - City:SOUDERTON
Practice Address - State:PA
Practice Address - Zip Code:18964-1110
Practice Address - Country:US
Practice Address - Phone:717-283-7774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP029501261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health