Provider Demographics
NPI:1164142584
Name:MILLER, BROOKLYN CHARITY
Entity Type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:CHARITY
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BROOKLYN
Other - Middle Name:CHAIRTY
Other - Last Name:MANNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1650 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-2841
Mailing Address - Country:US
Mailing Address - Phone:352-314-3760
Mailing Address - Fax:352-314-2909
Practice Address - Street 1:1650 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-2841
Practice Address - Country:US
Practice Address - Phone:352-314-3760
Practice Address - Fax:352-314-2909
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-219652106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty