Provider Demographics
NPI:1679398762
Name:LOUDER, BROOKE JOAN (CMT CMCP)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:JOAN
Last Name:LOUDER
Suffix:
Gender:F
Credentials:CMT CMCP
Other - Prefix:MISS
Other - First Name:BROOKE
Other - Middle Name:JOAN
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JUST GOT MARRIED
Mailing Address - Street 1:753 THIMBLE SHOALS BLVD STE 2A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-3575
Mailing Address - Country:US
Mailing Address - Phone:757-218-6325
Mailing Address - Fax:
Practice Address - Street 1:753 THIMBLE SHOALS BLVD STE 2A
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3575
Practice Address - Country:US
Practice Address - Phone:757-218-6325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019008822225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist