Provider Demographics
NPI:1790283638
Name:BROOKYS HAVEN
Entity Type:Organization
Organization Name:BROOKYS HAVEN
Other - Org Name:BROOKYS HAVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-423-1367
Mailing Address - Street 1:217 JONES ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4021
Mailing Address - Country:US
Mailing Address - Phone:318-423-1367
Mailing Address - Fax:318-216-3380
Practice Address - Street 1:217 JONES ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4021
Practice Address - Country:US
Practice Address - Phone:318-423-1367
Practice Address - Fax:318-216-3380
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKYS HAVEN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-25
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101Y00000X101Y00000X, 101YM0800X
LA101YM0800X101YM0800X, 251E00000X
LA103TH0004X261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty