Provider Demographics
NPI:1740914472
Name:BROOKS, STACY (LMBT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3718 CORA DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-4906
Mailing Address - Country:US
Mailing Address - Phone:336-618-0664
Mailing Address - Fax:
Practice Address - Street 1:2511 NEUDORF RD STE E
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8922
Practice Address - Country:US
Practice Address - Phone:336-618-0664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-09
Last Update Date:2022-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20086225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty