Provider Demographics
NPI:1013306018
Name:PERNICEK, BROOKE ALLISON (PLPC)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALLISON
Last Name:PERNICEK
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 S STEWART AVE
Mailing Address - Street 2:OFFICE 110
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2581
Mailing Address - Country:US
Mailing Address - Phone:402-525-8885
Mailing Address - Fax:
Practice Address - Street 1:1835 S STEWART AVE
Practice Address - Street 2:OFFICE 110
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2581
Practice Address - Country:US
Practice Address - Phone:402-525-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013008451101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional