Provider Demographics
NPI:1063657641
Name:BROOKS, VALERIE KARLENA (OTA)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:KARLENA
Last Name:BROOKS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-1916
Mailing Address - Country:US
Mailing Address - Phone:870-265-3950
Mailing Address - Fax:870-265-2525
Practice Address - Street 1:216 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653-1916
Practice Address - Country:US
Practice Address - Phone:870-265-3950
Practice Address - Fax:870-265-2525
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT0860174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR172424721Medicaid