Provider Demographics
NPI:1396276176
Name:BROOKS, GARY (LICDC-CS)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:BROOKS
Suffix:
Gender:M
Credentials:LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 GARFIELD LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:44047-1060
Mailing Address - Country:US
Mailing Address - Phone:440-994-4752
Mailing Address - Fax:
Practice Address - Street 1:179 GARFIELD LN
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:44047-1060
Practice Address - Country:US
Practice Address - Phone:440-994-4752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101100101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)