Provider Demographics
NPI:1164035846
Name:BROOKS, DEANNE A (SSP)
Entity Type:Individual
Prefix:
First Name:DEANNE
Middle Name:A
Last Name:BROOKS
Suffix:
Gender:F
Credentials:SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 E COUNTY ROAD 1800 N
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:IL
Mailing Address - Zip Code:62321-3102
Mailing Address - Country:US
Mailing Address - Phone:217-357-4900
Mailing Address - Fax:
Practice Address - Street 1:2461 N STATE HIGHWAY 96
Practice Address - Street 2:
Practice Address - City:NAUVOO
Practice Address - State:IL
Practice Address - Zip Code:62354-2200
Practice Address - Country:US
Practice Address - Phone:217-453-2231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL317750103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool