Healthcare Provider Details

I. General information

NPI: 1407526064
Provider Name (Legal Business Name): SHAINA BROOKS MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 UPPER MAIN ST
MORRISTOWN VT
05661-6600
US

IV. Provider business mailing address

PO BOX 133
STOWE VT
05672-0133
US

V. Phone/Fax

Practice location:
  • Phone: 404-717-9978
  • Fax:
Mailing address:
  • Phone: 404-717-9978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLI-456675
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: