Healthcare Provider Details

I. General information

NPI: 1083306526
Provider Name (Legal Business Name): BROOKE CHRISTINE CONRAD PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 E DEINHARD LN
MCCALL ID
83638-4703
US

IV. Provider business mailing address

PO BOX 2041
MCCALL ID
83638-2041
US

V. Phone/Fax

Practice location:
  • Phone: 208-634-8517
  • Fax: 208-292-2817
Mailing address:
  • Phone: 208-634-8517
  • Fax: 208-292-2817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-8506
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: