Provider Demographics
NPI:1588276299
Name:LAFAYETTE, BROOKE (PT, DPT)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:LAFAYETTE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 E 700 S UNIT C416
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-3184
Mailing Address - Country:US
Mailing Address - Phone:540-656-8434
Mailing Address - Fax:
Practice Address - Street 1:2572 E SOUTH WEBER DR STE 5
Practice Address - Street 2:
Practice Address - City:SOUTH WEBER
Practice Address - State:UT
Practice Address - Zip Code:84405-9550
Practice Address - Country:US
Practice Address - Phone:801-479-7045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
UT13789678-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer