Provider Demographics
NPI:1083799191
Name:BROOK, IRENE R (LCSW)
Entity Type:Individual
Prefix:MS
First Name:IRENE
Middle Name:R
Last Name:BROOK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5003 OQUINN BLVD SE STE B
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-7431
Mailing Address - Country:US
Mailing Address - Phone:910-457-6335
Mailing Address - Fax:910-457-6524
Practice Address - Street 1:5003 OQUINN BLVD SE STE B
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-7431
Practice Address - Country:US
Practice Address - Phone:910-457-6335
Practice Address - Fax:910-457-6524
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0047571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002889Medicaid
NC2879011Medicare ID - Type Unspecified