Provider Demographics
NPI:1043374788
Name:BROOKS, PHYLLIS (LICSW LIC 1043921)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:LICSW LIC 1043921
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ENVISION HEALTH AND HEALING
Mailing Address - Street 2:225 MAIN STREET
Mailing Address - City:WENHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01984
Mailing Address - Country:US
Mailing Address - Phone:978-468-0005
Mailing Address - Fax:978-774-9218
Practice Address - Street 1:225 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WENHAM
Practice Address - State:MA
Practice Address - Zip Code:01984
Practice Address - Country:US
Practice Address - Phone:978-468-0005
Practice Address - Fax:978-774-9218
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW 104392-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA288764OtherMHN
MAP03879OtherBCBS
MAP03879OtherBCBS