Provider Demographics
NPI:1194716365
Name:GULLICKSON, BROOK LYN (ATC, CSCS)
Entity type:Individual
Prefix:MRS
First Name:BROOK
Middle Name:LYN
Last Name:GULLICKSON
Suffix:
Gender:F
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:769 TUFTS AVE E
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-4060
Mailing Address - Country:US
Mailing Address - Phone:360-871-0799
Mailing Address - Fax:360-871-0799
Practice Address - Street 1:1015 NE HOSTMARK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-6204
Practice Address - Country:US
Practice Address - Phone:360-697-7726
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer