Provider Demographics
NPI:1891147526
Name:BROOKS, GLYNIS (CAADE)
Entity Type:Individual
Prefix:MS
First Name:GLYNIS
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:CAADE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8626 LOWER SACRAMENTO RD STE 41
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-1835
Mailing Address - Country:US
Mailing Address - Phone:209-242-4921
Mailing Address - Fax:
Practice Address - Street 1:8626 LOWER SACRAMENTO RD STE 41
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-1835
Practice Address - Country:US
Practice Address - Phone:209-242-4921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB0805061633101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)