Healthcare Provider Details

I. General information

NPI: 1750169637
Provider Name (Legal Business Name): BROOKELYNN GILMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BROOKELYN MACK

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25018 OAKHURST DR
SPRING TX
77386-2722
US

IV. Provider business mailing address

25018 OAKHURST DR
SPRING TX
77386-2722
US

V. Phone/Fax

Practice location:
  • Phone: 281-364-9695
  • Fax:
Mailing address:
  • Phone: 281-364-9695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2164098
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: