Provider Demographics
NPI:1245516970
Name:BROOKS, LEATRICE RENEE (PHD)
Entity type:Individual
Prefix:DR
First Name:LEATRICE
Middle Name:RENEE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5016 COOPERS LANDING DR
Mailing Address - Street 2:APT 3D
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-7647
Mailing Address - Country:US
Mailing Address - Phone:866-232-5389
Mailing Address - Fax:866-938-3746
Practice Address - Street 1:5016 COOPERS LANDING DR
Practice Address - Street 2:APT 3D
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49004-7647
Practice Address - Country:US
Practice Address - Phone:866-232-5389
Practice Address - Fax:866-938-3746
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015072103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1883502Medicaid