Healthcare Provider Details

I. General information

NPI: 1235692781
Provider Name (Legal Business Name): BROOKE K DUFFY DPT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BROOKE DIETSCHE

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 S WEBSTER AVE
GREEN BAY WI
54301-3505
US

IV. Provider business mailing address

PO BOX 22487
GREEN BAY WI
54305-2487
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-3500
  • Fax:
Mailing address:
  • Phone: 920-445-7210
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15887-24
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: