Provider Demographics
NPI:1629735592
Name:FAHNESTOCK, BROOKLYN E
Entity Type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:E
Last Name:FAHNESTOCK
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 1:4866 W 135TH ST
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66224-8715
Mailing Address - Country:US
Mailing Address - Phone:832-439-1896
Mailing Address - Fax:
Practice Address - Street 1:4866 W 135TH ST
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66224-8715
Practice Address - Country:US
Practice Address - Phone:832-439-1896
Practice Address - Fax:913-815-4127
Is Sole Proprietor?:No
Enumeration Date:2021-11-26
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician