Healthcare Provider Details

I. General information

NPI: 1265680359
Provider Name (Legal Business Name): BROOKE KENWORTHY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64444 FRANKFORT RD.
SALESVILLE OH
43778
US

IV. Provider business mailing address

64444 FRANKFORT RD.
SALESVILLE OH
43778
US

V. Phone/Fax

Practice location:
  • Phone: 740-679-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA05241
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: