Provider Demographics
NPI:1134702004
Name:ELDER, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:ELDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3044
Mailing Address - Street 2:
Mailing Address - City:WEST SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42564-3044
Mailing Address - Country:US
Mailing Address - Phone:606-687-2038
Mailing Address - Fax:606-200-3654
Practice Address - Street 1:200 BELMONT DRIVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501
Practice Address - Country:US
Practice Address - Phone:606-687-2038
Practice Address - Fax:606-200-3654
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY277207101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty