Provider Demographics
NPI:1083816300
Name:BROOKS, KELLY ANNETTE (LPC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANNETTE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 MANZANO ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-6306
Mailing Address - Country:US
Mailing Address - Phone:505-550-9536
Mailing Address - Fax:
Practice Address - Street 1:1224 PENNSYLVANIA ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7410
Practice Address - Country:US
Practice Address - Phone:505-550-9536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0099101101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional