Provider Demographics
NPI:1568840049
Name:DANIELS, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:DANIELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 LAKELAND AVE UNIT 12
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-2174
Mailing Address - Country:US
Mailing Address - Phone:631-732-4794
Mailing Address - Fax:
Practice Address - Street 1:1461 LAKELAND AVE UNIT 12
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-2174
Practice Address - Country:US
Practice Address - Phone:631-732-4794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-15
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092211104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02173802Medicaid