Provider Demographics
NPI:1619510914
Name:BROOKS, KEESHAWNA (PHD, NCSP, LP)
Entity Type:Individual
Prefix:DR
First Name:KEESHAWNA
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:PHD, NCSP, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FOREST PL APT P25
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1113
Mailing Address - Country:US
Mailing Address - Phone:773-559-1717
Mailing Address - Fax:
Practice Address - Street 1:325 N WELLS ST OFC 523
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-7024
Practice Address - Country:US
Practice Address - Phone:773-559-1717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-20
Last Update Date:2019-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TH0100X
IL2399934103TS0200X
MD06199103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool