Provider Demographics
NPI:1215251798
Name:THEBEAU, BROOKE C (PT)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:C
Last Name:THEBEAU
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:C
Other - Last Name:WIGGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:11140 THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66219-2301
Mailing Address - Country:US
Mailing Address - Phone:913-789-4075
Mailing Address - Fax:913-888-1728
Practice Address - Street 1:10090 NW PRAIRIE VIEW RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64153-1344
Practice Address - Country:US
Practice Address - Phone:913-789-4075
Practice Address - Fax:913-888-1728
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006004622225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist