Provider Demographics
NPI:1437490554
Name:BROOKE E. EGBERT, PSY.D., LLC
Entity Type:Organization
Organization Name:BROOKE E. EGBERT, PSY.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:E
Authorized Official - Last Name:EGBERT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:570-899-8902
Mailing Address - Street 1:317 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-9317
Mailing Address - Country:US
Mailing Address - Phone:570-899-8902
Mailing Address - Fax:570-824-5417
Practice Address - Street 1:1325 N RIVER ST
Practice Address - Street 2:SUITE 206
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18702-1838
Practice Address - Country:US
Practice Address - Phone:570-899-8902
Practice Address - Fax:570-824-5417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016379103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102470878 0003Medicaid