Provider Demographics
NPI:1174023949
Name:HOLBROOK, NATASHA AIMEE
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:AIMEE
Last Name:HOLBROOK
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 1:12075 CORPORATE PKWY STE 10
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-2665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12075 CORPORATE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-2664
Practice Address - Country:US
Practice Address - Phone:877-486-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-17
Last Update Date:2018-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIBACB365146106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician