Provider Demographics
NPI:1114495603
Name:BROOKS, DEANGELO
Entity Type:Individual
Prefix:
First Name:DEANGELO
Middle Name:
Last Name:BROOKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 S LAKESHORE DR APT 605
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-3930
Mailing Address - Country:US
Mailing Address - Phone:318-404-7134
Mailing Address - Fax:
Practice Address - Street 1:1105 ISLAND PARK BLVD APT 1126
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4783
Practice Address - Country:US
Practice Address - Phone:318-404-7134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health