Provider Demographics
NPI:1790345692
Name:BROOKS, BILLY BERNEARD (LCDC)
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:BERNEARD
Last Name:BROOKS
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3553 W HOUSTON HARTE EXPY
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-2664
Mailing Address - Country:US
Mailing Address - Phone:325-224-3481
Mailing Address - Fax:325-224-4923
Practice Address - Street 1:401 W TWOHIG AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-6321
Practice Address - Country:US
Practice Address - Phone:325-655-7777
Practice Address - Fax:325-659-4316
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10781101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX065284402Medicaid