1043314735 NPI number — MRS. MARTHA JANE BROOKS LCSW MSSW

Table of content: MRS. MARTHA JANE BROOKS LCSW MSSW (NPI 1043314735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043314735 NPI number — MRS. MARTHA JANE BROOKS LCSW MSSW

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILSON
Provider Other First Name:
MARTHA
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043314735
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9054
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37615-9054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-467-3600
Provider Business Mailing Address Fax Number:
423-467-3696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 CAMPBELL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SNEEDVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-733-2216
Provider Business Practice Location Address Fax Number:
423-733-2450
Provider Enumeration Date:
09/12/2006

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: 104100000X , with the licence number:  LCSW1015 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12850 . This is a "UBH JOHN DEERE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1002526 . This is a "CIGNA MCC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 132697 . This is a "VALUEOPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3085273 . This is a "MAGELLAN SUMMIT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12850 . This is a "UBH EMPLOYER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12850 . This is a "UBH SENIOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3085273 . This is a "MAGELLAN NAVIGATOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 138847 . This is a "HANCOCK CO ANTHEM PREF" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3085273 . This is a "MAGELLAN PINNACLE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 334969 . This is a "GROUP VALUEOPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12850 . This is a "UBH HEALTHPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 138847 . This is a "HANCOCK CO ANTHEM PROF" identifier . This identifiers is of the category "OTHER".




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