Healthcare Provider Details

I. General information

NPI: 1326512187
Provider Name (Legal Business Name): BROOKE NICHOLSON DPT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 SUDLOW ST
MILES CITY MT
59301-5037
US

IV. Provider business mailing address

2402 SUDLOW ST
MILES CITY MT
59301-5037
US

V. Phone/Fax

Practice location:
  • Phone: 406-399-1878
  • Fax:
Mailing address:
  • Phone: 406-399-1878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number27094
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: