Provider Demographics
NPI:1558649517
Name:ROBERTS, BROOKE (PHD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 BROTHERS RD B
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6975
Mailing Address - Country:US
Mailing Address - Phone:505-795-5566
Mailing Address - Fax:505-807-0285
Practice Address - Street 1:2204 BROTHERS RD B
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6975
Practice Address - Country:US
Practice Address - Phone:505-795-5566
Practice Address - Fax:505-807-0285
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1211103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist