=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356155113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKS' WELLNESS MASSAGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2025
-----------------------------------------------------
Last Update Date | 02/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 806 IKE MOONEY RD NE
-----------------------------------------------------
City | SILVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97381-8707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-562-0654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 806 IKE MOONEY RD NE
-----------------------------------------------------
City | SILVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97381-8707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-562-0654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MASSAGE THERAPIST
-----------------------------------------------------
Name | SHANNON ANN BROOKS
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 503-562-0654
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------