Provider Demographics
NPI:1700238938
Name:BROOKS, BENEDRA
Entity Type:Individual
Prefix:
First Name:BENEDRA
Middle Name:
Last Name:BROOKS
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 1:1705 FELICIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:TALLULAH
Mailing Address - State:LOUISIANA
Mailing Address - Zip Code:71282
Mailing Address - Country:UM
Mailing Address - Phone:318-574-1232
Mailing Address - Fax:318-574-8646
Practice Address - Street 1:1705 FELICIA AVE
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282
Practice Address - Country:US
Practice Address - Phone:318-574-1232
Practice Address - Fax:318-574-8646
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator