Healthcare Provider Details

I. General information

NPI: 1003807819
Provider Name (Legal Business Name): MARK E BROOKS PT, DSC, ECS, OCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 JASON DR STE 5
RICHMOND KY
40475-2785
US

IV. Provider business mailing address

312 JASON DR STE 5
RICHMOND KY
40475-2785
US

V. Phone/Fax

Practice location:
  • Phone: 859-625-0001
  • Fax:
Mailing address:
  • Phone: 859-625-0001
  • Fax: 859-625-1109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT38134
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number001746
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License Number001746
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: