Provider Demographics
NPI:1043201221
Name:BROOKS, DOUGLAS A (PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A
Last Name:BROOKS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2702 CUNNINGHAM AVE
Mailing Address - Street 2:STE A
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1570
Mailing Address - Country:US
Mailing Address - Phone:417-782-1910
Mailing Address - Fax:417-782-1844
Practice Address - Street 1:2702 CUNNINGHAM AVE
Practice Address - Street 2:STE A
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1570
Practice Address - Country:US
Practice Address - Phone:417-782-1910
Practice Address - Fax:417-782-1844
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00218103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493312300Medicaid
KS100240090BMedicaid
MO493312300Medicaid