Healthcare Provider Details

I. General information

NPI: 1265916035
Provider Name (Legal Business Name): REBECCA BROOKSHER MED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 SAINT JOSEPH BOULEVARD EAST APT 2
MONTREAL QUEBEC
H2J1L3
CA

IV. Provider business mailing address

1147 SAINT JOSEPH BOULEVARD EAST APT 2
MONTREAL QUEBEC
H2J1L3
CA

V. Phone/Fax

Practice location:
  • Phone: 438-522-6326
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number362378B
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: