Provider Demographics
NPI:1750674545
Name:MOLLER, BROOKE HELEN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:HELEN
Last Name:MOLLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:HELEN
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 PINE ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-5384
Mailing Address - Country:US
Mailing Address - Phone:716-579-5270
Mailing Address - Fax:
Practice Address - Street 1:500 PINE ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-5384
Practice Address - Country:US
Practice Address - Phone:716-579-5270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080721-1104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker