Provider Demographics
NPI:1659013258
Name:HARRIS, BROOKLYN
Entity Type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:
Last Name:HARRIS
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 1:903 PARKVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:HEWITT
Mailing Address - State:TX
Mailing Address - Zip Code:76643-3265
Mailing Address - Country:US
Mailing Address - Phone:903-312-1315
Mailing Address - Fax:
Practice Address - Street 1:900 WEST HWY 6
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76643
Practice Address - Country:US
Practice Address - Phone:903-312-1315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22208437106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXRBT-22-208437OtherBACB