Provider Demographics
NPI:1043923642
Name:BROOKS, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 VIRGINIA ST E STE 400
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2835
Mailing Address - Country:US
Mailing Address - Phone:681-313-4759
Mailing Address - Fax:
Practice Address - Street 1:900 VIRGINIA ST E STE 400
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2835
Practice Address - Country:US
Practice Address - Phone:681-313-4759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-29
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV27646164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1487758710Medicaid