Basic Information
| Provider Information | |||||||||
| NPI: | 1255563680 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKMEYER | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | BOYNTON HEALTH SERVICE | ||||||||
| Address2: | 410 CHURCH STREET SE | ||||||||
| City: | MINNEAPLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126258400 | ||||||||
| FaxNumber: | 6126251434 | ||||||||
| Practice Location | |||||||||
| Address1: | BOYNTON HEALTH SERVICE | ||||||||
| Address2: | 410 CHURCH STREET SE | ||||||||
| City: | MINNEAPLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126258400 | ||||||||
| FaxNumber: | 6126251434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2009 | ||||||||
| LastUpdateDate: | 10/22/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | OR 6019 | OR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT60103916 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00836811 | 01 | WA | RR MEDICARE | OTHER | 0253485 | 01 | OR | WASHINGTON L&I | OTHER | 500611221 | 05 | OR | MEDICAID | 8568024 | 05 | WA | MEDICAID |