Provider Demographics
NPI:1639958135
Name:HAAN, BROOKE NICOLE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:HAAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BROKE
Other - Middle Name:NICOLE
Other - Last Name:HAAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:124 CAPULET DR STE 102
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-4538
Mailing Address - Country:US
Mailing Address - Phone:904-429-3859
Mailing Address - Fax:
Practice Address - Street 1:124 CAPULET DR STE 102
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-4538
Practice Address - Country:US
Practice Address - Phone:904-429-3859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician