Provider Demographics
NPI:1376033811
Name:ANDRUSIAK, BROOKE LYNN
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LYNN
Last Name:ANDRUSIAK
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 1:7087 SNOW AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-9749
Mailing Address - Country:US
Mailing Address - Phone:616-260-9467
Mailing Address - Fax:
Practice Address - Street 1:2100 RAYBROOK ST SE STE 203
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5783
Practice Address - Country:US
Practice Address - Phone:616-954-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MI6851109900104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst