Provider Demographics
NPI:1740882067
Name:ETIE, BROOKE ELISABETH (LCSW)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELISABETH
Last Name:ETIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3331 GLADIOLUS LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75233-3801
Mailing Address - Country:US
Mailing Address - Phone:318-663-1840
Mailing Address - Fax:
Practice Address - Street 1:3331 GLADIOLUS LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75233-3801
Practice Address - Country:US
Practice Address - Phone:318-663-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX558291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical