Provider Demographics
NPI:1376016808
Name:WILSON, BROOKE L
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:L
Last Name:WILSON
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 1:1501 MADISON RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1706
Mailing Address - Country:US
Mailing Address - Phone:513-354-5200
Mailing Address - Fax:513-354-7115
Practice Address - Street 1:1501 MADISON RD
Practice Address - Street 2:
Practice Address - City:WALNUT HILLS
Practice Address - State:OH
Practice Address - Zip Code:45206-1706
Practice Address - Country:US
Practice Address - Phone:513-354-5200
Practice Address - Fax:513-354-7115
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00000OtherLICENSURE BOARD