Provider Demographics
NPI:1477323152
Name:BROOKSIDE FAMILY THERAPY, LLC
Entity Type:Organization
Organization Name:BROOKSIDE FAMILY THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:571-331-9704
Mailing Address - Street 1:7118 KNOTTY OAK LN
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20112-3235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9105A OWENS DR STE 102
Practice Address - Street 2:
Practice Address - City:MANASSAS PARK
Practice Address - State:VA
Practice Address - Zip Code:20111-4852
Practice Address - Country:US
Practice Address - Phone:571-445-0265
Practice Address - Fax:855-755-7769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty