Provider Demographics
NPI:1629010723
Name:BROOKS, DECHANILE JOHNSON (MA)
Entity Type:Individual
Prefix:
First Name:DECHANILE
Middle Name:JOHNSON
Last Name:BROOKS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4833 MOUNT OLIVE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27312-8252
Mailing Address - Country:US
Mailing Address - Phone:336-376-1613
Mailing Address - Fax:336-376-1613
Practice Address - Street 1:180 PROVIDENCE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2206
Practice Address - Country:US
Practice Address - Phone:919-493-4412
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1628103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC046MUOtherBCBS PIN
NC6107152Medicaid