Provider Demographics
NPI:1629069620
Name:BROOKS, JUNE J (EDD)
Entity Type:Individual
Prefix:
First Name:JUNE
Middle Name:J
Last Name:BROOKS
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100039
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76185-0039
Mailing Address - Country:US
Mailing Address - Phone:817-546-8212
Mailing Address - Fax:817-546-8215
Practice Address - Street 1:COLONIAL MANOR NURSING HOME
Practice Address - Street 2:2035 GRANBURY STREET
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033
Practice Address - Country:US
Practice Address - Phone:817-654-9134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-1049103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122328102Medicaid
TX122328102Medicaid