Provider Demographics
NPI:1508673260
Name:WITTY, BROOK ADALE
Entity type:Individual
Prefix:
First Name:BROOK
Middle Name:ADALE
Last Name:WITTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62264 SKI RUN RD
Mailing Address - Street 2:
Mailing Address - City:JOSEPH
Mailing Address - State:OR
Mailing Address - Zip Code:97846-8209
Mailing Address - Country:US
Mailing Address - Phone:541-620-0849
Mailing Address - Fax:
Practice Address - Street 1:606 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-5140
Practice Address - Country:US
Practice Address - Phone:541-426-4524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist