Provider Demographics
NPI:1407610066
Name:WILLIS, BROOKE LILLIANNA (LSAA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LILLIANNA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8601 GOLF COURSE RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5775
Mailing Address - Country:US
Mailing Address - Phone:505-305-0902
Mailing Address - Fax:
Practice Address - Street 1:8601 GOLF COURSE RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5775
Practice Address - Country:US
Practice Address - Phone:505-305-0902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2024-0112101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)