Healthcare Provider Details

I. General information

NPI: 1780418590
Provider Name (Legal Business Name): BROOKE BLACKMON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15400 NORTHLINE RD
SOUTHGATE MI
48195-2689
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 734-285-0100
  • Fax: 734-285-0101
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502008669
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: