Provider Demographics
NPI:1114178928
Name:HARDY, BROOK L (MA)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:L
Last Name:HARDY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 COTTAGE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46616-1203
Mailing Address - Country:US
Mailing Address - Phone:574-401-0941
Mailing Address - Fax:
Practice Address - Street 1:616 E COLFAX AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2827
Practice Address - Country:US
Practice Address - Phone:574-401-0941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002242A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health