Provider Demographics
NPI:1851329346
Name:BROOKS, MICHELE L (CNS)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:L
Last Name:BROOKS
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16881
Mailing Address - Street 2:STE 35
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79490-6881
Mailing Address - Country:US
Mailing Address - Phone:806-252-1507
Mailing Address - Fax:806-785-4929
Practice Address - Street 1:4004 82ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-1900
Practice Address - Country:US
Practice Address - Phone:806-722-3110
Practice Address - Fax:806-722-3115
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07317133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172561601Medicaid
TX172561601Medicaid
TX8D3218Medicare ID - Type Unspecified