Provider Demographics
NPI:1265288005
Name:GONZALES, BROOKE ALEXANDRA (BT)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALEXANDRA
Last Name:GONZALES
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 LILAC AVE
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23325-3814
Mailing Address - Country:US
Mailing Address - Phone:757-338-5439
Mailing Address - Fax:
Practice Address - Street 1:5621 TIDEWATER DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23509-1497
Practice Address - Country:US
Practice Address - Phone:757-416-5290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician