Provider Demographics
NPI:1679502991
Name:DANIEL, BROOKE (PT)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:DANIEL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1632 WHITNEY ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5210
Mailing Address - Country:US
Mailing Address - Phone:706-414-1345
Mailing Address - Fax:
Practice Address - Street 1:2315 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6246
Practice Address - Country:US
Practice Address - Phone:706-364-6172
Practice Address - Fax:706-364-6172
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008302225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist