Provider Demographics
NPI:1396584496
Name:BROOKS, IVY
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:
Other - Last Name:EYTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:510 S BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-5709
Mailing Address - Country:US
Mailing Address - Phone:402-516-8748
Mailing Address - Fax:
Practice Address - Street 1:14301 FNB PKWY STE 100
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-7200
Practice Address - Country:US
Practice Address - Phone:402-807-7447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NERBT-24-333057106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician