1730228057 NPI number — MRS. BROOKE MARY WALLACE LCSW, BCD

Table of content: MRS. BROOKE MARY WALLACE LCSW, BCD (NPI 1730228057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730228057 NPI number — MRS. BROOKE MARY WALLACE LCSW, BCD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
BROOKE
Provider Middle Name:
MARY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW, BCD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALLACE
Provider Other First Name:
BROOKE
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW, BCD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1730228057
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3551 ROGER BROOKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JBSA FT SAM HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78234-4504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-508-9058
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 BERGQUIST DR
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
LACKLAND A F B
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78236-9907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-508-9058
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  51643 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com