Provider Demographics
NPI:1649330069
Name:BROOKINS, ANTIONETTE DENISE
Entity type:Individual
Prefix:MRS
First Name:ANTIONETTE
Middle Name:DENISE
Last Name:BROOKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5275 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-7007
Mailing Address - Country:US
Mailing Address - Phone:559-709-9169
Mailing Address - Fax:559-225-5369
Practice Address - Street 1:3723 E DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-5106
Practice Address - Country:US
Practice Address - Phone:559-709-9169
Practice Address - Fax:559-225-5369
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80890106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA225400000XMedicare ID - Type UnspecifiedALL OTHER UNLISCENSED MEN