Provider Demographics
NPI:1093789836
Name:BROOKS, PHILLIP JAY (LMHC)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:JAY
Last Name:BROOKS
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 DEAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237
Mailing Address - Country:US
Mailing Address - Phone:941-953-4318
Mailing Address - Fax:
Practice Address - Street 1:1750 17TH ST
Practice Address - Street 2:BLDG J-2
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34234-8632
Practice Address - Country:US
Practice Address - Phone:941-552-2078
Practice Address - Fax:941-552-2079
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH3098101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH 3098OtherLICENSED MH COUNSELOR
FL764872300Medicaid