Provider Demographics
NPI:1043405335
Name:WHALEN, BROOKE J (LICSW)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:J
Last Name:WHALEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:J
Other - Last Name:MOWATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:215 STRATTON RD
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4621
Mailing Address - Country:US
Mailing Address - Phone:802-855-2027
Mailing Address - Fax:802-855-2053
Practice Address - Street 1:215 STRATTON RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4621
Practice Address - Country:US
Practice Address - Phone:802-773-3386
Practice Address - Fax:802-773-4578
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900012021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1014090Medicaid
001585201Medicare PIN