Provider Demographics
NPI:1033449400
Name:BROOKS, DANA NOELLE (MA, MFT)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:NOELLE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7337
Mailing Address - Country:US
Mailing Address - Phone:541-773-3863
Mailing Address - Fax:541-776-2892
Practice Address - Street 1:19 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7337
Practice Address - Country:US
Practice Address - Phone:541-773-3863
Practice Address - Fax:541-776-2892
Is Sole Proprietor?:No
Enumeration Date:2010-01-07
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 47905106H00000X
ORT1169106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227698Medicaid