Provider Demographics
NPI:1942797360
Name:SALISBURY, BROOK NICOLE
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:NICOLE
Last Name:SALISBURY
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 1:7650 E REALTY RD
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-9333
Mailing Address - Country:US
Mailing Address - Phone:209-263-8301
Mailing Address - Fax:
Practice Address - Street 1:2291 W MARCH LN STE C101
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6669
Practice Address - Country:US
Practice Address - Phone:209-263-8301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6708OtherLEARNING ARTS