Provider Demographics
NPI:1659786747
Name:WILY, BROOKE (LCSW)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:WILY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:IBANEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:194 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-2631
Mailing Address - Country:US
Mailing Address - Phone:801-785-1169
Mailing Address - Fax:801-785-1154
Practice Address - Street 1:194 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-2631
Practice Address - Country:US
Practice Address - Phone:801-785-1169
Practice Address - Fax:801-785-1154
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT526223135021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical