Provider Demographics
NPI:1306278361
Name:WINTER, BROOKE (ATC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:WINTER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 ISANTI PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ISANTI
Mailing Address - State:MN
Mailing Address - Zip Code:55040-7508
Mailing Address - Country:US
Mailing Address - Phone:763-458-0101
Mailing Address - Fax:
Practice Address - Street 1:5466 SAINT CROIX TRL
Practice Address - Street 2:SUITE 107
Practice Address - City:NORTH BRANCH
Practice Address - State:MN
Practice Address - Zip Code:55056-4204
Practice Address - Country:US
Practice Address - Phone:651-674-7589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer