Provider Demographics
NPI:1114464583
Name:KLEEBERGER, BROOKE J (LISW)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:J
Last Name:KLEEBERGER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 S SHOOP AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1702
Mailing Address - Country:US
Mailing Address - Phone:419-330-2790
Mailing Address - Fax:419-330-2774
Practice Address - Street 1:725 S SHOOP AVE
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1702
Practice Address - Country:US
Practice Address - Phone:419-330-2790
Practice Address - Fax:419-330-2774
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1700027104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker