1659894509 NPI number — MRS. ELIZABETH ANTOINETTE BROOKE MS, NCC, LPC

Table of content: MRS. ELIZABETH ANTOINETTE BROOKE MS, NCC, LPC (NPI 1659894509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659894509 NPI number — MRS. ELIZABETH ANTOINETTE BROOKE MS, NCC, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROOKE
Provider First Name:
ELIZABETH
Provider Middle Name:
ANTOINETTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, NCC, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMALLWOOD
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
ANTOINETTE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, NCC, LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659894509
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10003 WEBSTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDEN ON GAULEY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26208-7713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-226-5725
Provider Business Mailing Address Fax Number:
304-226-3274

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMERSVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26651-1343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-872-1663
Provider Business Practice Location Address Fax Number:
304-872-1804
Provider Enumeration Date:
07/24/2017

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: 101YP2500X , with the licence number:  2290 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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