Basic Information
| Provider Information | |||||||||
| NPI: | 1003163205 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | BRITTANY | ||||||||
| MiddleName: | RENAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCORKHILL | ||||||||
| OtherFirstName: | BRITTANY | ||||||||
| OtherMiddleName: | RENAE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 561 WAYSIDE PLZ | ||||||||
| Address2: | |||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864033830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517563745 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1615 CURLEW DR | ||||||||
| Address2: | |||||||||
| City: | AMMON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834064718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085161204 | ||||||||
| FaxNumber: | 2085776477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2012 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9959 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 6787 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 736884 | 05 | AZ | MEDICAID |