1447293907 NPI number — MRS. HEATHER D BROOKS PT

Table of content: MRS. HEATHER D BROOKS PT (NPI 1447293907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447293907 NPI number — MRS. HEATHER D BROOKS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROOKS
Provider First Name:
HEATHER
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SPENCER
Provider Other First Name:
HEATHER
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1447293907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
405 E MARSHALL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILMER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75644-2331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-402-1052
Provider Business Mailing Address Fax Number:
888-335-2090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 E MARSHALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILMER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75644-2331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-402-1052
Provider Business Practice Location Address Fax Number:
888-335-2090
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 1145621 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1145621 . This is a "PT #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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