Provider Demographics
NPI:1700415379
Name:FORTENBERRY, BROOKE (LCSW)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 INDIAN RIVER RD STE C
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-3649
Mailing Address - Country:US
Mailing Address - Phone:203-497-3867
Mailing Address - Fax:203-298-0494
Practice Address - Street 1:240 INDIAN RIVER RD STE C
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3649
Practice Address - Country:US
Practice Address - Phone:203-497-3867
Practice Address - Fax:203-298-0494
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT110021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical