Provider Demographics
NPI:1821446444
Name:BROOKS, DESIRAE
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10694 HUNTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-5918
Mailing Address - Country:US
Mailing Address - Phone:407-496-6414
Mailing Address - Fax:
Practice Address - Street 1:1000 W BROADWAY ST
Practice Address - Street 2:STE 214
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9262
Practice Address - Country:US
Practice Address - Phone:407-359-5693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-16-15624OtherBACB