Basic Information
| Provider Information | |||||||||
| NPI: | 1467717868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | LOVE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOVE | ||||||||
| OtherFirstName: | BROOKE | ||||||||
| OtherMiddleName: | JEAN | ||||||||
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| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1650 LYNDON FARM CT STE 300 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402235005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566774000 | ||||||||
| FaxNumber: | 8562343014 | ||||||||
| Practice Location | |||||||||
| Address1: | 1075 VIRGINIA DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190343108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157178463 | ||||||||
| FaxNumber: | 2156194555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2012 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT025214 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 0400086262 | VT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | LPT-010681 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.