=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992452874
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKE DANIEL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2022
-----------------------------------------------------
Last Update Date | 03/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13985 COUNTY ROAD 763
-----------------------------------------------------
City | ESSEX
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63846-7158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-625-3726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13985 COUNTY ROAD 763
-----------------------------------------------------
City | ESSEX
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63846-7158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-625-3726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251G0304X
-----------------------------------------------------
Taxonomy Name | Geriatric Physical Therapist
-----------------------------------------------------
License Number | 2016037382
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------