1558107961 NPI number — BROOKS PSYCHOLOGICAL SERVICES, LLC

Table of content: (NPI 1558107961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558107961 NPI number — BROOKS PSYCHOLOGICAL SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKS PSYCHOLOGICAL SERVICES, LLC
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:
1558107961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
61 N PLAINS INDUSTRIAL RD # 188
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLINGFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06492-5841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-491-0650
Provider Business Mailing Address Fax Number:
203-303-9062

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
816 OAK CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27610-9538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-491-0650
Provider Business Practice Location Address Fax Number:
203-303-9062
Provider Enumeration Date:
07/04/2024

Additional Information

Authorized Official

Authorized Official Last Name:
BROOKS
Authorized Official First Name:
TENESHA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/THERAPIST
Authorized Official Telephone Number:
203-491-0650

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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