Provider Demographics
NPI:1144824137
Name:THERIAULT, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8025 N US HIGHWAY 89 LOT 3
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1209
Mailing Address - Country:US
Mailing Address - Phone:928-593-0423
Mailing Address - Fax:
Practice Address - Street 1:1585 S PLAZA WAY STE 150
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7156
Practice Address - Country:US
Practice Address - Phone:928-226-1556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-24171225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist