1386657740 NPI number — MRS. ALICE BROOKS LCSW

Table of content: MRS. ALICE BROOKS LCSW (NPI 1386657740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386657740 NPI number — MRS. ALICE BROOKS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROOKS
Provider First Name:
ALICE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROOKS
Provider Other First Name:
LISSIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1386657740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 ASHFORD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AVON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06001-4552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-205-1829
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 ASHFORD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AVON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06001-4552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-205-1829
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2006

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:  002890 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 079524 . This is a "MHN PROVIDER NUMBER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 140002890 CT01 . This is a "BLUE CROSS PROVIDER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P3203033 . This is a "OXFORD PROVIDER NUMBER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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