1356492128 NPI number — RUSSELL E. BROOKER, ED.D., P.C.

Table of content: (NPI 1356492128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356492128 NPI number — RUSSELL E. BROOKER, ED.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUSSELL E. BROOKER, ED.D., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1356492128
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
181 14TH ST NE
Provider Second Line Business Mailing Address:
SUITE 450
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30309-3674
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-873-6178
Provider Business Mailing Address Fax Number:
404-873-0342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
181 14TH ST NE
Provider Second Line Business Practice Location Address:
SUITE 450
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30309-3674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-873-6178
Provider Business Practice Location Address Fax Number:
404-873-0342
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BROOKER
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
EDWIN
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
404-873-6178

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  360 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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