Provider Demographics
NPI:1326136060
Name:BROOKS, MIRA J (AUD CCC-A)
Entity Type:Individual
Prefix:MS
First Name:MIRA
Middle Name:J
Last Name:BROOKS
Suffix:
Gender:F
Credentials:AUD CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19991 HALL RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-4254
Mailing Address - Country:US
Mailing Address - Phone:586-263-4401
Mailing Address - Fax:586-263-4402
Practice Address - Street 1:24431 SHERMAN ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1850
Practice Address - Country:US
Practice Address - Phone:248-752-8855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000163237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
0E01477OtherBCBS
MI0E06192015Medicare PIN