Provider Demographics
NPI:1639659287
Name:CUNNINGHAM, BROOKE ELLEN (PTA)
Entity type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:ELLEN
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 CARLOW DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-4328
Mailing Address - Country:US
Mailing Address - Phone:832-385-4762
Mailing Address - Fax:
Practice Address - Street 1:907 GARWOOD ST
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:TX
Practice Address - Zip Code:78957-1117
Practice Address - Country:US
Practice Address - Phone:512-237-4606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2121713225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant