Provider Demographics
NPI:1538870928
Name:WOODSIDE, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:WOODSIDE
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:PO BOX 416501
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6501
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:
Practice Address - Street 1:2103 N VETERANS PKWY STE 328
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-0919
Practice Address - Country:US
Practice Address - Phone:309-948-6469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist