Provider Demographics
NPI:1134527179
Name:STANLEY, BROOKE (EDS)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:STANLEY
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-9678
Mailing Address - Country:US
Mailing Address - Phone:740-385-8517
Mailing Address - Fax:
Practice Address - Street 1:2019 E FRONT ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-9678
Practice Address - Country:US
Practice Address - Phone:740-385-8517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3107952171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator