Provider Demographics
NPI:1790475143
Name:BROOKS, DAVID (CLINICAL SUPERVISOR)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:BROOKS
Suffix:
Gender:M
Credentials:CLINICAL SUPERVISOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2528 W PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-5926
Mailing Address - Country:US
Mailing Address - Phone:814-490-0128
Mailing Address - Fax:
Practice Address - Street 1:2528 W PALMETTO ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-5926
Practice Address - Country:US
Practice Address - Phone:814-490-0128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA5474101YA0400X
SCCS-20113101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)