Provider Demographics
NPI:1922580778
Name:ANSOTEGUI, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:ANSOTEGUI
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:PO BOX 705
Mailing Address - Street 2:
Mailing Address - City:CONDON
Mailing Address - State:OR
Mailing Address - Zip Code:97823-0705
Mailing Address - Country:US
Mailing Address - Phone:541-384-2666
Mailing Address - Fax:
Practice Address - Street 1:422 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CONDON
Practice Address - State:OR
Practice Address - Zip Code:97823-7651
Practice Address - Country:US
Practice Address - Phone:541-384-2666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty