Provider Demographics
NPI:1700853504
Name:BROOK LANE HEALTH SERVICES
Entity Type:Organization
Organization Name:BROOK LANE HEALTH SERVICES
Other - Org Name:PSYCHOLOGIST GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:FLOYD
Authorized Official - Middle Name:
Authorized Official - Last Name:KLAUKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-733-0330
Mailing Address - Street 1:PO BOX 1945
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-1945
Mailing Address - Country:US
Mailing Address - Phone:301-733-0330
Mailing Address - Fax:301-733-4038
Practice Address - Street 1:13218 BROOKLANE DR
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-1435
Practice Address - Country:US
Practice Address - Phone:301-733-0330
Practice Address - Fax:301-733-4038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD214003Medicare ID - Type Unspecified