Provider Demographics
NPI:1679838635
Name:BROOKS, TYNESHIA A (MS CPCI)
Entity Type:Individual
Prefix:
First Name:TYNESHIA
Middle Name:A
Last Name:BROOKS
Suffix:
Gender:F
Credentials:MS CPCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 92168
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89009-2168
Mailing Address - Country:US
Mailing Address - Phone:702-498-1743
Mailing Address - Fax:
Practice Address - Street 1:913 CRESCENT FALLS ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89011-2516
Practice Address - Country:US
Practice Address - Phone:702-498-1743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 175T00000X, 172V00000X
NVCP0280172V00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1427386267Medicaid