Provider Demographics
NPI:1255689568
Name:LATHER-MCELLIGOTT, BROOKE ALLISON
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALLISON
Last Name:LATHER-MCELLIGOTT
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 1:1332 N 171ST ST
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-5454
Mailing Address - Country:US
Mailing Address - Phone:206-429-5221
Mailing Address - Fax:
Practice Address - Street 1:9730 3RD AVE NE STE 101
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2023
Practice Address - Country:US
Practice Address - Phone:206-429-5221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60624570101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2067003Medicaid