1730854381 NPI number — SONJI LOUISE BROOKS

Table of content: SONJI LOUISE BROOKS (NPI 1730854381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730854381 NPI number — SONJI LOUISE BROOKS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROOKS
Provider First Name:
SONJI
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1730854381
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 COOPER RD STE 11
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VOORHEES
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08043-3800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-282-2208
Provider Business Mailing Address Fax Number:
856-291-5079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 WHITE HORSE RD W STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VOORHEES
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08043-3673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-282-2208
Provider Business Practice Location Address Fax Number:
856-291-5079
Provider Enumeration Date:
08/14/2021

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: 163WH0200X , with the licence number:  08240501 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 815455655 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 815455655 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".