Provider Demographics
NPI:1508649682
Name:BALLENBERG, BROOKE TAYLOR (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:TAYLOR
Last Name:BALLENBERG
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N BENJAMIN LN STE 200
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5094
Mailing Address - Country:US
Mailing Address - Phone:208-287-7660
Mailing Address - Fax:
Practice Address - Street 1:400 N BENJAMIN LN STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5094
Practice Address - Country:US
Practice Address - Phone:208-287-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-9584101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor