Healthcare Provider Details

I. General information

NPI: 1902785686
Provider Name (Legal Business Name): BROOKE MARIE WILKIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 04/04/2026
Certification Date: 04/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1057
ADA MI
49301-1057
US

IV. Provider business mailing address

PO BOX 1057
ADA MI
49301-1057
US

V. Phone/Fax

Practice location:
  • Phone: 616-682-7429
  • Fax: 616-825-6096
Mailing address:
  • Phone: 616-682-7429
  • Fax: 616-825-6096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number88643
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: