Provider Demographics
NPI:1649882606
Name:BROOKE BRODY LICENSED CLINICAL SOCIAL WORKER, PC
Entity type:Organization
Organization Name:BROOKE BRODY LICENSED CLINICAL SOCIAL WORKER, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:H
Authorized Official - Last Name:BRODY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:240-994-4926
Mailing Address - Street 1:621A 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952
Mailing Address - Country:US
Mailing Address - Phone:240-994-4926
Mailing Address - Fax:
Practice Address - Street 1:621A 2ND ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952
Practice Address - Country:US
Practice Address - Phone:707-708-3090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-20
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness