Provider Demographics
NPI:1518542307
Name:SMITH, BROOKE KRISTEN
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:KRISTEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:KRISTEN
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3120 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3229
Mailing Address - Country:US
Mailing Address - Phone:920-657-1780
Mailing Address - Fax:
Practice Address - Street 1:3120 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3229
Practice Address - Country:US
Practice Address - Phone:920-657-1780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4916-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional