Provider Demographics
NPI:1831764588
Name:BROCKHOUSE, ABIGAIL RAE
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:RAE
Last Name:BROCKHOUSE
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 1:609 BOND ST APT A14
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-4979
Mailing Address - Country:US
Mailing Address - Phone:218-689-5016
Mailing Address - Fax:
Practice Address - Street 1:308 WARHAWK WAY
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71209-2715
Practice Address - Country:US
Practice Address - Phone:318-342-3565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3284892255A2300X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer