Provider Demographics
NPI:1578945226
Name:SULLIVAN, BROOKE DANIELLE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:DANIELLE
Last Name:SULLIVAN
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 1:6621 STEPHENS RANCH RD
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-1146
Mailing Address - Country:US
Mailing Address - Phone:909-596-7484
Mailing Address - Fax:909-593-4750
Practice Address - Street 1:6621 STEPHENS RANCH RD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-1146
Practice Address - Country:US
Practice Address - Phone:909-596-7484
Practice Address - Fax:909-593-4750
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)