Provider Demographics
NPI:1457582884
Name:BROOKS, DIANE ADELE (PT)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ADELE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:ADELE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:294 W CARLOS AVE
Mailing Address - Street 2:P.O. BOX 668
Mailing Address - City:HOLBROOK
Mailing Address - State:AZ
Mailing Address - Zip Code:86025-1846
Mailing Address - Country:US
Mailing Address - Phone:928-524-2123
Mailing Address - Fax:928-524-6367
Practice Address - Street 1:294 W CARLOS AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025-1846
Practice Address - Country:US
Practice Address - Phone:928-524-2123
Practice Address - Fax:928-524-6367
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006005274225100000X
CA6486225100000X
AZ8621225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist