Healthcare Provider Details

I. General information

NPI: 1548636533
Provider Name (Legal Business Name): BROOKE VAUGHN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BROOKE DOLBERG DPT

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 E HIGHLAND AVE STE 200
PHOENIX AZ
85016-4777
US

IV. Provider business mailing address

15410 S MOUNTAIN PKWY SUITE 112
PHOENIX AZ
85044-6691
US

V. Phone/Fax

Practice location:
  • Phone: 602-778-0900
  • Fax:
Mailing address:
  • Phone: 480-706-1161
  • Fax: 480-706-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11745
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: