Provider Demographics
NPI:1679182984
Name:BROOKE OSTERHOUDT, LLC
Entity Type:Organization
Organization Name:BROOKE OSTERHOUDT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-408-4455
Mailing Address - Street 1:16 HAMILTONS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-8911
Mailing Address - Country:US
Mailing Address - Phone:303-408-4455
Mailing Address - Fax:
Practice Address - Street 1:4341 CHARLOTTE HWY STE 202
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-7062
Practice Address - Country:US
Practice Address - Phone:303-408-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKE OSTERHOUDT, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty